ABSTRACT 
 
 
 
 
Title of Document: EAST ASIAN INTERNATIONAL TRAINEES 
EXPERIENCE CONDUCTING THERAPY IN 
THE US: A QUALITATIVE INVESTIGATION  
  
 Jingqing Liu, Doctor of Philosophy, 2013 
  
Directed By: Professor Clara E. Hill, Doctor of Philosophy. 
Department of Psychology 
 
 
In the present study, the author investigated East-Asian international counseling trainees? 
experience of conducting therapy in the US, particularly challenges East-Asian trainees 
are facing, how East-Asian trainees cope with these challenges, how East-Asian trainees? 
cultural backgrounds affect their clinical work, and East-Asian trainees? experience with 
clinical training. Ten East-Asian international trainees (from China, Korea, Japan, and 
Taiwan) were interviewed. For each participant, two 1-2 hours phone interview were 
conducted, approximately one week apart. In the first interview, participants were asked 
to discuss their experience with clinical training in the US, to reflect on challenges that 
they faced that related to doing therapy in the US, and to describe their coping strategies. 
In the second interview, participants were asked to discuss in details two cases in which 
their cultural backgrounds facilitated/hindered their clinical work. The Consensual 
Qualitative Research?Hill et. al, 2005?is used for data analysis. The results indicated 
that East-Asian trainees deal with challenges such as discrimination/distrust from their 
  
clients, language barrier, a lack of understanding of nuances of American culture, 
countertransference due to cultural conflict, discomfort working with emotions, and 
difficulty being direct with clients. East-Asian trainees cope with these challenges by 
seeking support, addressing cultural issues with clients, improving English skills, using 
cognitive restructuring, using avoidance, and practicing self-care. Results also indicated 
that East-Asian international trainees? cultural backgrounds/experience (e.g., their 
understanding of Asian cultural values and their bicultural experiences) can be an asset to 
their clinical work. Implications for training and research are discussed. 
. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
EAST ASIAN INTERNATIONAL TRAINEES EXPERIENCE CONDUCTING 
THERAPY IN THE US: A QUALITATIVE INVESTIGATION  
 
 
 
By 
 
 
        Jingqing Liu 
 
 
 
 
 
Dissertation submitted to the Faculty of the Graduate School of the  
University of Maryland, College Park, in partial fulfillment 
of the requirements for the degree of 
Doctor of Philosophy 
2013 
 
 
 
 
 
 
 
 
 
 
Advisory Committee: 
Professor Clara E. Hill, Ph.D. (Chair) 
Assistant Professor Lea Dougherty, Ph.D. 
Professor  Mary Ann Hoffman, Ph.D. 
Yi-Jiun Lin, Ph.D. 
Assistant Professor Matthew J. Miller, Ph.D 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
? Copyright by 
Jingqing Liu 
2013 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ii 
 
Acknowledgements 
My deepest gratitude goes to Clara Hill for her superb auditing, gentle 
encouragement, and tireless support both in the completion of this dissertation and 
throughout my doctoral program; I could not dream of a better mentor. In addition, I 
want to thank all participants who openly shared their experiences with me. It was 
incredibly rewarding and energizing to hear their struggles and triumphs as East-
 Asian therapists-in-training.  I would also like to say thanks to Lea Dougherty, Mary 
Ann Hoffman, Yi-Jiun Lin, and Matt Miller for serving on my advisory committee 
and for their valuable feedback. 
Special thanks to my incredibly dedicated and amazing research team?
 Graham Knowlton, Maria Lauer, Rachel Viegas, Robyne Rivers, Minji Yang, and 
Trish Raque-Bogdan. They shared in my excitement about the topic, pushed through 
the very long CQR process with me, and helped me keep a sense of humor when 
things were stressful. Their contributions and effort were priceless. Also thank Harold 
and Na-Yeun for volunteering their time to help me pilot the interview protocol.  
Finally, I would like to thank the mentors and friends who supported me 
through this process: Ann, Beth, Mimi, Erica, Sara, Nicole, Pat, Mike, Brian, Richard,  
Mark, and Greg. Special thanks to my parents, who have always inspired me, trusted 
my decisions, and supported me unconditionally. 
  
 
 iii 
 
Table of Contents 
 
Acknowledgements ....................................................................................................... ii 
Table of Contents ......................................................................................................... iii 
Chapter 1: Introduction ................................................................................................. 1 
Chapter 2: Literature Review ........................................................................................ 3 
Chapter 3: Statement of Problem ................................................................................ 41 
Chapter 4: Method ...................................................................................................... 44 
Chapter 5:  Results ...................................................................................................... 56 
Chapter 6:  Discussion ................................................................................................ 80 
Appendices ................................................................................................................ 102 
        Appendix A: Recruitment Emails..................................................................... 102 
        Appendix B: Demographic Questionnnaire...................................................... 105 
        Appendix C: Interview Protocol....................................................................... 106 
       Appendix  D: Collectivism subscale of the AAVS ?Multidimensional???.109 
        Appendix E: Table 1........................................................................................  110 
References ................................................................................................................. 131 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
Chapter 1: Introduction 
A growing number of international graduate students have enrolled in counseling 
psychology programs in the United States (Heppner et al, 2008). Ng (2006a) surveyed 
176 CACREP-accredited counseling programs and found that in the spring of 2004, 
nearly half of 176 programs had international students enrolled, and international students 
accounted for 9% of the total enrollment. However, few empirical studies have been 
conducted to examine the experiences of international trainees in conducting therapy. 
The existing literature on international trainees in mental health training programs 
touched on some challenges that international trainees may face when they working with 
clients. For instance, it has been found that English proficiency affected international 
trainees? anxiety levels and clinical skills (Chen, 2004; Mittal & Wieling ,2006; Ng, 
2006b). In addition, international trainees typically experienced conflict between their 
cultures of origin and the mainstream theories of western therapy/counseling (Mittal & 
Wieling, 2006; Ng, 2006b; Pattison, 2003). Another challenge for international trainees 
was that they often worried about how their clients perceive them, and sometimes 
experienced overt or covert discrimination from their clients (Mittal & Wieling, 2006). In 
terms of the within-group difference among international students, counseling educators 
perceived that non-western international students struggled more than western 
international students with both language proficiency and cultural conflicts (Ng, 2006b). 
Several factors were identified as facilitative to international trainees? growth: 
constructive relationships with fellow trainees, professors, and supervisors as well as a 
training environment that is culturally open-minded and responsive to individuals? 
training needs (Chen, 2004), discussion of cultural differences with clients or learning to 
 
 2 
 
be more at ease with clients refusing their services (Mittal & Wieling, 2006), becoming 
more assertive and direct with faculty/supervisors about their needs and differences 
(Mittal & Wieling, 2006).  
Although these studies have touched on aspects of international trainees that may 
affect their experiences of working with clients, they focused on examination of training 
experiences in general rather than an in-depth investigation of international trainees? 
experience of doing therapy. For instance, although cultural conflicts have been noted in 
several studies (Mittal & Wieling, 2006; Pattison, 2003), the impact of cultural conflicts 
on international trainees? clinical work has not been explored. In addition, none of these 
studies were conducted on international counseling students who received their training 
in the United States. Moreover, the samples of these studies included international 
trainees from various cultural backgrounds and thus it is hard to examine the impact of a 
particular culture (e.g. collectivistic culture) on international trainees? experience.  
In order to broaden our understanding of international trainees and to address some 
limitations of previous studies, the present study focused in-depth on East-Asian 
international trainees? experience of conducting counseling in the United States. 
Specifically, the present study examined 1) what challenges East-Asian international 
trainees face when working with clients in the US, 2) how East-Asian international 
trainees cope with these challenges, 3) how East-Asian international trainees? cultural 
backgrounds affect counseling process, 4) What aspects of clinical training that East 
Asian international trainees receive in the US are helpful or need to be improved. The 
present study is qualitative, because qualitative methods enable researchers to capture the 
complexity and richness of human experience (Polkinghorne, 2005). 
 
 3 
 
Chapter 2: Literature Review 
In this chapter, I first review the literature on the development of therapists to 
provide a context within which the clinical development of international trainees can be 
understood. Then I review studies on the experiences of international students in mental 
health training programs, and try to identify challenges that international trainees face in 
their clinical work. Next, I summarize studies that are related to how collectivistic culture 
may affect the therapy process, and briefly reviewed articles concerning the development 
of counseling psychology in East Asia. Lastly, I provide an overview of consensual 
qualitative research (CQR), which is the qualitative method that I will use in the present 
study. 
The Development of Therapists 
In this section, I first review studies on how novice therapists develop over time. I 
then examine studies that compared novice therapists to experienced therapists. The last 
part of this section is a review of studies on what factors facilitate the development of 
therapists. 
The Development of Novice Therapists 
Hill, Charles, and Reed (1981) conducted a longitudinal study to investigate changes 
in counseling skills among doctoral level counseling trainees. The authors followed 12 
students (7 female, 5 male; 10 Caucasian, 2 Black) through 3 years of training in an 
APA-approved doctoral program in counseling psychology. Six participants had 
extensive prior experience of counseling, whereas the other six had minimal experience 
of doing counseling prior to their entrance into the doctoral program. During the fall 
semester of each year, each participant was paired up with two volunteer clients (one 
 
 4 
 
female and one male) to conduct 12 brief counseling sessions (six sessions per client), 
and these sessions were recorded and transcribed. The transcripts of all counseling 
sessions were coded in terms of the types of counselor responses, the level of counselor 
activity, counselor anxiety, and the quality of the session. At the end of the third year, all 
participants were interviewed following a structured interview protocol. Specifically, 
participants were asked to describe the changes in their behaviors and feelings in working 
with their clients. 
According to Hill et al. (1981), participants increased their use of minimal 
encouragers and decreased their use of questions over the course of training. In addition, 
participants maintained acceptable levels of activity, anxiety, and quality. When 
interviewed at the end of the third year, about half of the participants reported increased 
confidence in working with clients and a reduced tendency to become overinvested in 
their clients. In addition, most participants reported being more able to focus on the 
clients and experiencing less performance anxiety. Some participants also reported that 
they shifted from using empathic techniques to experiencing a more genuine empathy 
with their clients. In response to a query about changes in skills, most participants 
reported that they changed in higher-order counseling abilities, such as timing, 
appropriateness of intervention, and conceptualization of client dynamics, rather than in 
basic counselor skills. When queried about the experiences that helped them change their 
counseling styles, most participants cited supervision and/or client contact. 
By using a mixed-method design, Hill, Charles, and Reed (1981) provided rich data 
on how trainees developed clinically in the first three years of their doctoral training. 
However, because the majority of participants (10 out of 12) were Caucasian, the results 
 
 5 
 
of their study might not reflect the development of international students. In addition, half 
of their participants reported having extensive clinical experience before they started their 
doctoral level training, and thus should be considered as experienced trainees. As a result, 
the findings of their study might not completely capture the development of 
inexperienced trainees. In addition, their qualitative analyses were not done 
systematically using an accepted method.  
Williams, Judge, Hill, and Hoffman (1997) used quantitative and qualitative (CQR) 
methods to investigate novice trainees? personal reactions during counseling sessions and 
management strategies. The participants of this study were seven pre-practicum trainees 
(6 female, 1 male; 1 African American, 6 Caucasian). Each trainee had weekly one-hour 
counseling sessions with volunteer clients, and received one hour weekly individual 
supervision. After each counseling session, trainees completed the State-Trait Anxiety 
Inventory (STAI), Counseling Self-estimate Inventory (COSE), and open ended 
questions about their reactions and management strategies. In addition, both clients and 
supervisors completed open-ended questions similar to those completed by the trainee.  
According to Williams et al. (1997), trainees? anxiety decreased over time, and their 
overall therapeutic skill and skill in managing countertransference increased. Qualitative 
data yielded several domains. The first domain was feeling and reactions, such that all 
trainees reported feeling anxious or uncomfortable; most trainees reported being 
unengaged or distracted by their personal issues, by their self-awareness of their feelings 
or of their intervention planning, or by the feeling that there was an agenda to follow. 
Most of the trainees also reported positive feelings, such as empathy or connection, 
during their sessions. The second domain was personal concerns. Most trainees reported 
 
 6 
 
being concerned about their therapeutic skills and performance, and struggled with 
understanding and defining their role as therapists. The third domain was management 
strategies. Most of the trainees reported focusing on their clients as a strategy to manage 
their reactions, although two trainees reported using their own self-awareness to manage 
their reactions, and one trainee reported suppressing his/her feelings as a strategy. The 
authors provided interesting descriptions of pre-practicum trainees? in-session 
experiences, but their results might not capture experiences of international trainees.  
Howard, Inman, and Altman (2006) explored critical incidents from the perspective 
of novice counselor trainees during their first year of supervised practicum. The authors 
defined critical incidents (CIs) as ?significant learning moments, turning points, or 
moments of realization that were identified by the trainees as making a significant 
contribution to their professional growth? (p. 88). Nine participants (8 White women and 
1 White man) who were in their second semester of their first master-level practicum 
were given the definition of the CIs and asked to keep a weekly journal regarding their 
experience of CIs. Participants? journal entries were analyzed using a discovery-oriented 
method. Specifically, two white advanced doctoral students coded the CIs independently 
first and then reached consensus. A South-Asian American professor served as the 
auditor.  
According to Howard, Inman, and Altman (2006), a total of 157 CIs were identified; 
several overarching categories emerged. Specifically, a third of all CIs were related to 
professional identity. These CIs involved role identification (i.e. identifying with a 
specific theoretical orientation, feeling a sense of belonging within the practicum site 
community, and discovering unique personal dynamics brought to the counselor role), 
 
 7 
 
trainees? recognition of unfamiliar elements of their new role as a counselor (i.e. 
scheduling appointments, assessing suicide risk, and setting boundaries), and trainees? 
feeling of being restricted by their status of being a trainee). A fifth of CIs were 
experiences that had an impact on trainees? self-efficacy, such as incidents that helped 
them to see their strengths as a therapist (e.g., being trusted by clients, being able to 
listen, providing emotional support or specific guidance). Nearly 10% of the CIs were 
experiences that helped trainees to obtain/change their viewpoint of the counseling 
process (some trainees described moments when a particular theory resonated with them, 
and other trainees discussed experiences that helped them to understand the importance 
of tolerating ambiguity in therapy). By examining the critical incidents, the authors shed 
light on experiences that led to novice trainees? clinical development. However, all 
participants of their study were Caucasian, and thus their findings might not capture 
culture-related critical incidents that minority or international trainees would be more 
likely to experience. 
Hill, Sullivan, Knox, and Schlosser (2007) conducted a qualitative study to examine 
beginning trainees? development as psychotherapists. The participants of this study were 
five Caucasian doctoral-level trainees who enrolled in a pre-practicum class, and all five 
participants had minimal prior clinical experience. During the pre-practicum class, 
participants read and discussed a variety of therapy theories and practiced helping skills. 
In addition, participants conducted 10-12 50-min counseling sessions with volunteer 
clients who were upper-level undergraduate students. All participants received live 
supervision from advanced doctoral students. For data collection, participants were 
instructed to write weekly journal entries on any of the following topics: helping skills, 
 
 8 
 
competence as a psychotherapist, countertransference, anxiety, self-efficacy, reactions to 
supervision, learning about psychotherapy, cultural issues, ethics, the process of 
becoming a psychotherapist, reactions to class, or anything else that seemed related to 
their development as psychotherapists. The first two authors of this study read 
participants? journals and provided them feedback.  
From the data analysis using CQR, Hill et al. identified four domains: challenges 
related to becoming psychotherapists, gains related to becoming psychotherapists, 
supervision, and experiences other than supervision that fostered awareness. In terms of 
challenges related to becoming psychotherapists, participants reported being self-critical, 
feeling under- or over-identified with their clients, feeling disappointed when their clients 
did not conform to their expectations for ideal client behaviors, experiencing difficulty 
using certain helping skills (e.g. open questions and insight skills), and experiencing 
difficulties managing the logistics of sessions. In terms of gains related to becoming 
psychotherapists, participants reported increased self-efficacy, decreased anxiety, 
improvement in using exploration and insight skills (particularly in using reflection of 
feelings, restatement, open question, silence, challenges, and immediacy), and being able 
to connect with their clients. In terms of supervision, participants preferred a more 
directive, dialectical style of supervision, and found supervisors? support and specific 
constructive feedback helpful. Participants used a variety of techniques to manage their 
anxiety during sessions, such as positive self-talk and focusing on helping skills and the 
client. The authors provided rich qualitative data on novice trainees? development over a 
pre-practicum, but the findings of their study might not capture the experiences of 
international trainees? experiences. 
 
 9 
 
 In sum, previous studies on the development of novice trainees show that as novice 
counseling trainees obtain more clinical experience, their performance anxiety decrease 
and their confidence increase (Hill et al., 1981; Hill et al., 2007). In addition, counseling 
trainees primarily improve in terms of helping skills during pre-practicum (Hill et al., 
2007; Williams et al., 1997), whereas , post-prepracticum trainees develope more higher-
 order counseling skills (i.e. appropriateness of intervention, case conceptualization, and 
maintaining appropriate boundary) and professional identities (i.e. identification with the 
counselor role or specific theoretical orientation (Hill et al., 1981; Howard et al., 2006). 
Furthermore, novice counseling trainees? reactions related to their clinical work has been 
examined in several studies. The results of these studies suggest that novice counseling 
trainees typically experience some negative feelings, such as feeling anxious, disengaged 
or distracted, frustrated or disappointed at their clients, and self-critical (Hill et al., 2007; 
Williams et al., 1997). During their counseling sessions, trainees often manage their 
negative feelings through self-awareness (Williams et al., 1997), focusing on the clients 
or positive self-talk (Hill et al., 2007). Between sessions, trainees usually manage their 
negative feelings through supervision (Hill et al., 2007). A major limitation of the 
literature on the development of novice counseling trainees is that the majority of 
participants were Caucasian, and so generalization to ethnic minority or international 
trainees is questionable.  
The Comparison between Novice and Experienced Therapists 
Martin, Slemon, Hiebert, and Hallberg (1989) examined differences in 
conceptualization between experienced and novice counselors. Eleven experienced 
counselors and 12 novice counselors completed a cognitive mapping task (CMT), such 
 
 10 
 
that they  free associated to stimulus sentences for a minute and then arranged their 
associations into a conceptual map. The stimulus sentences used in this study included 
one sentence to assess participants? general conceptual ability (i.e. the general CMT ) and 
one sentence to assess participants? conceptualization of specific problems of individual 
clients (i.e. the specific CMT). The authors found that experienced counselors generated 
more extensive conceptualizations on the general CMT, whereas novice counselor 
generated more extensive conceptualizations on the specific CMT. The results suggested 
that experienced counselors had more extensive abstract knowledge of counseling than 
did novice counselors.   
Etringer, Hillerbrand, and Claiborn (1995) discussed the cognitive competencies that 
distinguish expert from novice counselors. They hypothesized that expert counselors 
encode information in abstract, problem-relevant categories that are connected by 
underlying conceptual principles, whereas novice counselors store information using 
superficial, problem-irrelevant cues. They also hypothesized that expert counselors 
compared to novice counselors would be more able to translate declarative knowledge 
into procedural knowledge. In addition, the authors speculated that expert counselors 
would be better able to recognize patterns than novice counselors, and would be more 
able to reframe a problem with ambiguous information to a recognizable problem, and 
therefore would be more efficient in problem-solving than novice counselors. Although 
the authors provide insightful observations on the difference between novice and 
experienced therapists, their hypotheses need to be empirically tested.  
Mayfield, Kardash, and Kivlighan (1999) examined the difference in knowledge 
structure about clients between experienced and novice counselors by using concept 
 
 11 
 
mapping tasks and association tasks. Specifically, four experienced counselors and five 
novice counselors were asked to read a transcript of an intake session with a client. Then 
participants were given cards with printed client statements, and asked to sort the cards 
into similar groups of client statements. After all client statements were sorted into 
different clusters, participants were asked to construct a cognitive map in which the 
relationships among the groups of client statements were specified. Results showed that 
novice counselors as compared with experienced counselors constructed more clusters in 
their cognitive maps, indicated fewer reciprocal relationships, were more likely to group 
client statements based on temporal proximity, and spent more time constructing their 
cognitive maps. The results of this study suggested that in comparison to experienced 
counselors, novice counselors attended to more superficial details and organized client 
information based on more superficial cues. The findings also indicated that novice 
counselors required more time to process information than did experienced counselors.  
Orlinsky and R?nnestad (2005) employed a cross-sectional approach to investigate 
the difference between novice and experienced therapists with regard to their self-
 reported experience of therapeutic work. This study was one component of a big study 
that was conducted on a multinational sample of 5000 psychotherapists. Participants of 
the big study were recruited from the United States, Europe, and Korea. However, only 
participants from western countries (i.e. the United States, Norway, and Germany) were 
included for this cross-sectional analysis. The authors categorized participants into six 
cohorts based on the duration of practice(less than 1.5 years of experience were 
considered to be novice therapists; participants with between 1.5 to 3 years were 
considered apprentice therapists; participants with 3.5 to 7 years were considered 
 
 12 
 
graduate therapists; participants with 7 to 15 years were considered established therapists; 
participants with 15 to 25 years were considered seasoned therapists; participants with 
more than 25 years were senior therapists).  
Orlinsky and R?nnestad (2005) found that therapists with more experience 
experienced fewer difficulties in practice, particularly expressed less self-doubt about 
their abilities to work effectively with clients. In the face of difficulties in practice, senior 
therapists were less likely to seek consultation than were novice and apprentice 
therapists. Instead, seasoned and senior therapists coped with difficulties by exercising 
reflective control (i.e., reviewing and examining the difficulty privately) and problem 
solving with patients (i.e., sharing their experience of the difficulty with patients and 
trying to collaborate with them to work through the difficulty). In terms of their 
relationship with their clients, therapists in all cohorts experienced themselves as highly 
invested in relating to their clients, although there was a slight increase in the level of 
investment as therapists gained more experience. Therapists in the more experienced 
cohort were more warmly accepting and less reserved with their clients than were 
therapists in less experienced cohort. When they were in session with their clients, novice 
and apprentice therapists experienced more anxiety and less boredom than did 
established, seasoned, and senior therapists. However, the authors also noted that all 
therapists experienced more positive feelings (e.g., being stimulated, engrossed and 
inspired) than negative feelings in session. Orlinsky and R?nnestad?s (2005) findings 
suggest that novice and experienced therapists differed in their coping strategies in the 
face of difficulties in practice and in their emotional reactions in sessions. However, their 
findings may reflect only Western novice and experienced therapists.  
 
 13 
 
In sum, the literature suggests that novice and experienced therapists differ in their 
cognitive competencies (particularly in their capacities to organize clients? information in 
a conceptually meaningful way), and in their understanding of the general therapy 
process. Specifically, novice therapists tend to organize clients? information based on 
superficial cues and struggle with understanding the general process of therapy and how 
the general process can be applied to specific cases. In contrast, experienced therapists 
tend to organize clients? information in a conceptually meaningful way and are able to 
apply their understandings of the general process of therapy to specific cases, and this 
helps them process clients? information efficiently (Martin et al., 1989; Mayfield et al., 
1999). In addition, the comparison between novice and experienced therapists shows that 
experienced therapists tend to cope with clinical difficulties through self-reflection and 
collaboration with clients, whereas novice therapists tend to cope through consultation 
(Orlinsky & R?nnestad, 2005). In terms of reactions during therapy sessions, novice 
therapists tend to experience more anxiety, more self-doubt, and less boredom than do 
experienced therapists (Orlinsky & R?nnestad, 2005). Novice therapists also tend to be 
more reserved and less warmly accepting of their clients than do experienced therapists 
(Orlinsky & R?nnestad, 2005), perhaps because novice therapists? anxiety and self-doubt 
prevent them from being fully present with their clients. However, all of these studies 
have been conducted on western trainees, and therefore the findings may not be 
applicable to East-Asian international trainees. 
Factors that Facilitate the Development of Expertise 
Jennings and Skovholt (1999) interviewed 10 peer-nominated Caucasian master 
therapists and qualitatively examined the cognitive, emotional, and relational 
 
 14 
 
characteristics of master therapists. Of the 10 participants (7 women and 3 men), there 
were 6 PhD licensed psychologists, 3 licensed master?s level social workers and 1 
licensed psychiatrist. The age of participants ranged from 50 to 72 years (M = 59.00, SD 
= 7.89), while their years of experience ranged from 21 to 41 years (M = 29.50, SD = 
6.62). The theoretical orientations of participants included psychodynamic (n = 4), family 
system (n = 2), integrative (n = 2), and existential-humanistic (n = 2). All participants 
worked full time in private practice with clients for both short- and long-term therapy. 
The first author conducted a 90-minute semi-structured in-person interview with each 
participant. Then both authors and a research assistant analyzed the transcripts using an 
inductive analysis procedure. Specifically, the authors read each paragraph and wrote one 
or two words to represent the concept of the paragraph. Then each concept was written on 
a card and all concepts were sorted into 40 preliminary themes. Then the first author 
conducted a 60-min follow-up interview with each participant to obtain their input on the 
preliminary themes. During the follow-up interview, participants evaluated how well the 
results of the data analysis reflected their individual experiences. The themes were then 
modified based on participants? feedback. Jennings and Skovholt (1999) reported nine 
themes that reflected the characteristics of at least 8 of the 10 master therapists. 
Specifically, master therapists were voracious learners who benefited from accumulated 
experiences of clinical work. In addition, master therapists valued cognitive complexity 
and the ambiguity of the human condition. In terms of the emotional characteristics, 
master therapists were emotionally receptive (i.e. being self-aware, reflective, non-
 defensive, and open to feedback). Master therapists also were mentally healthy and 
mature, used to attending to their own emotional well-being, and aware of how their 
 
 15 
 
emotional health affected the quality of their work. In terms of relational characteristics, 
master therapists had developed strong relationship skills, particularly within their 
families of origin. In addition, master therapists believed that the foundation of 
therapeutic change was a strong working alliance and were expert in using their 
relationship skills in their work with clients. Unfortunately, the findings might not be 
applicable to the development of therapists in other areas of the United States or in other 
regions of the world. 
Jennings et al. (2008) extended Jennings and Skvoholt?s (1999) examination on 
characteristics of master therapists in Minnesota to a sample of Singaporean master 
therapists. They interviewed nine peer-nominated Singaporean expert therapists (five 
men, four women) who ranged in age from 40 to 59 years (M = 50.56, SD = 6.19). The 
participants? experiences of practicing therapy ranged from 10 to 34 years (M = 18.4, SD 
= 7.6). Three participants had PhDs in clinical or counseling psychology, three had 
master degrees in social work or counseling), two had bachelor?s degrees, and one had 
extensive applied training and 34 years of experience but no formal degree. The majority 
of the participants were of Chinese descent. Eight participants received their training in 
western countries (six in the US, one in Canada, and one in England), and only one 
participant received training locally. As far as theoretical orientation, approximately half 
of participants identified themselves as family therapists (n = 5), while the rest identified 
themselves as either psychodynamic (n = 2) or existential-humanistic (n = 2).  
According to Jennings et al. (2008), all participants were interviewed in English by 
the first author and his Singaporean colleague following a semi-structured interview 
protocol similar to the one used by Jennings and Skovholt (1999). Data were analyzed by 
 
 16 
 
a team of three researchers, and a Singaporean professor who taught in an American 
University served as the auditor. The data analyses were mainly guided by grounded 
theory procedure, but several components of the CQR, such as the decision-making 
process (i.e. multiple researchers to code transcripts independently and then to reach the 
conclusion consensually) and cross-analysis, were borrowed. 
 Jennings et al. (2008) reported that master therapists in Singapore were empathic, 
nonjudgmental, and respectful to their clients. In terms of individual factors that 
contributed to the development of expertise, participants reported that clinical 
experiences, self-awareness, and humility (i.e. recognizing one?s limitations and learning 
from mistakes) were important components of their development of expertise. 
Interestingly, although all participants were regarded highly by their peers, they 
periodically experienced self-doubt about their competence, which motivated them to 
improve their clinical skills. All participants spoke about the importance of ongoing 
professional growth and that they benefited from teaching/training other therapists. In 
addition, participants identified several challenges of professional development in 
Singapore. For instance, they reported that Singaporean trainees struggled more with 
using basic counseling skills, because these skills were not natural for them.  
Jennings et al. (2008) conducted a qualitative meta-analysis to compare themes 
emerged in this study to themes revealed by Jennings and Skovholt (1999). They found 
greater similarities than differences between the two samples, and argued for the 
existence of universal characteristics of master therapists regardless of cultural 
differences. However, the authors noted that Singaporean master therapists reported self-
 
 17 
 
doubt as a motivator for their professional development, whereas American master 
therapists studied did not discuss self-doubt. 
Orlinsky and R?nnestad (2005) examined the professional development of 5000 
psychotherapists from the United States, Europe, and Korea. The majority of participants 
identified themselves as either psychologists or psychiatrists, but a few were social 
workers, counselors, or clinical nurses. Participants? theoretical orientations ranged 
widely, and nearly half of participants reported being influenced by more than one 
theoretical orientation. The duration of practice varied widely among participants (M = 
11.2, SD = 8.9 years). All participants completed a survey including a total of 392 items. 
The authors examined individual characteristics that predicted therapists? cumulative 
development (defined as ?the therapist?s overall experience of development from his or 
her first days of therapeutic work to the present time,? p. 106). They found that the 
employment of a variety of treatment modalities (e.g. providing both individual and 
couple therapy) and the number of years of clinical experience predicted cumulative 
development. In addition, participants perceived that direct contact with clients, 
supervision, and personal therapy were the most influential factors facilitating their 
development. Unfortunately, the authors did not examine whether there were between-
 group differences among the different national groups.    
In summary, direct contact with clients seem to be facilitative of the development of 
therapists? expertise (Jennings et al. 2008; Jennings & Skovholt, 1999; Orlinsky & 
R?nnestad, 2005). Therapists seem to develop their expertise through engaging in 
activities such as supervision and personal therapy (Orlinsky & R?nnestad, 2005), and 
teaching/training other therapists (Jennings et al. 2008), and self-awareness helps 
 
 18 
 
therapists grow (Jennings et al. 2008; Jennings & Skovholt, 1999). In terms of the 
culture-specific factors in the development of expertise, Singapore master therapists 
reported humility as a facilitating factor for their professional development (Jennings et 
al. 2008).  
International Students in Mental Health Training Programs 
Pattison (2003) interviewed 12 international students from Africa, Eastern Asia (i.e. 
China, Japan, and Taiwan), Europe, and the Middle East who had completed a one-year 
M. Ed program in Guidance and Counseling at the University of Newcastle about their 
expectations and their experiences of becoming counselors. Most participants were 
involved in counseling-related activities either as an educator or a practitioner after 
graduation. Each participant was interviewed by an independent researcher for one hour 
using a semi-structured interview protocol. The author, a person-centered counselor and 
researcher, listened to all tapes and used grounded theory to analyze the data related to 
three pre-determined themes (perceptions and expectations, training processes, training 
outcomes). Results showed that participants enrolled in the program with the expectation 
that the training would increase their theoretical knowledge and enable them to solve 
problems in practice. In terms of the process of becoming counselors, the majority of 
participants reported that the mainstream theories of counseling were culturally different 
from their own experience (e.g., a Chinese participant said that the person-centered 
concept of counselor congruence went against her/his culture). Participants also reported 
cultural differences in learning styles and expression of feelings. With regard to the 
impact of the training, all participants reported increased cultural awareness, which they 
believed would enhance their clinical work, and increased confidence. Unfortunately, the 
 
 19 
 
author did not examine her own biases with regard to the research questions, which may 
have been problematic given that the author conducted all the qualitative analyses 
without external auditing.   
Chen (2004) conducted a qualitative study to explore non-Western counseling 
trainees? life career experiences. The author interviewed 8 participants (5 recent 
immigrates, 3 international students; 4 males and 4 females) who either enrolled in or 
completed a counseling-related degree program in British Columbia, Canada. All 
participants had lived in Canada for at least two years, and half had lived in Canada 
between 5 and 10 years. Two of the participants were trainees at the guidance diploma 
level, while the other six were Master level trainees. All participants were interviewed 
using a semi-structured interview format, and each interview lasted 1.5 to 2.5 hours. 
Transcripts were analyzed using an ethnographic field work framework. Specifically, the 
author wrote a ?third-person? story/narrative for each participant, sent the story/narrative 
to the participant for validation, and revised it based on the participant?s suggestions and 
comments. At the end, a general narrative was developed from the major themes that 
emerged from the eight individual stories. According to the author, these non-Western 
counseling trainees were individuals who had been well-educated and successful 
professionals in their own fields prior to their coming to Canada. Many of them reported 
a strong interest in psychology and human behaviors. Most of them had actively searched 
for alternative career options. Once they decided to go abroad, they began to take actions 
in implementing their plan through collecting as much information about the host country 
as they could and seeking available financial resources. 
 
 20 
 
According to Chen (2004), the acquisition of counseling knowledge and skills went 
hand-in-hand with the enhancement of language capacity in English. Many participants 
reported anxiety around personal sharing in the skill-training context. They identified 
three common sources of the anxiety: culturally oriented perceptions and experiences, 
self-perceived deficiency in English, and an over-sensitive personality that often led to 
lowered self-confidence. In terms of environmental factors that facilitated their learning, 
participants reported that a positive learning environment in which they experienced a 
constructive relationship with fellow trainees, professors, and/or supervisors facilitated 
their adjustment. Trainees also reported that a training environment that was culturally 
open-minded and responsive to trainees? needs was facilitative. In addition, trainees 
reported that a sense of humor, a sense of humility, an easy-going and open 
communication manner, and the ability to put things into perspectives had facilitated their 
adjustment. In terms of their growth in the process of counselor training, all participants 
reported enhanced self-awareness and increased interpersonal skills as a result of their 
training. Although very interesting and thorough, these results may not be representative 
of the training experiences of doctoral-level trainees in the United States, given that Ph.D 
and master?s level training differed in terms of the amount of individual attention given to 
each trainee and the levels of performance trainees are expected to exhibit.      
Morris and Lee (2004) examined clients? experiences of working with MFT trainees 
who were non-native speakers of English. A seven-item questionnaire was mailed to 50 
White clients who received family therapy at a university-based clinic by non-native 
English-speaking trainees; 15 clients completed the questionnaire and returned it to the 
researchers. Clients? written responses to open-ended questions were reviewed, and 
 
 21 
 
several thematic categories (i.e. language challenge, cultural distinction, and non-issue) 
emerged. Specifically, for the category of language challenge, clients discussed their 
experiences of working with non-native English-speaking therapists. Clients reported 
having to listen carefully in order to understand their therapists, and noticed that their 
non-native English-speaking therapists spoke carefully to ensure being understood. 
Importantly, clients reported that the language challenge was not experienced as a 
stumbling block in therapy. In terms of the cultural distinction, clients? responses varied 
widely. Some clients viewed the cultural differences between them and their therapists as 
a concern, whereas others were intrigued by cultural differences and expressed desire for 
more cultural discussion. There was one client who perceived no cultural difference, 
because he/she perceived the therapist as very western in thoughts and interpretations. In 
terms of the non-issue, several participants indicated that their therapists being non-native 
speakers of English was relatively unimportant compared to their overall experiences of 
therapy as a process of working through their problems.  
Morris and Lee (2004)?s study on clients? experience of working with non-native 
English-speaking trainees yielded some interesting findings. First, although clients 
admitted that it required more effort on their parts to understand their non-native English-
 speaking therapists, most clients did not consider having a non-native English Speaking 
therapist as hindering to or even important for their therapy experience. Second, in 
comparison to the language issue, clients seemed more concerned about working with a 
therapist from a different cultural background, although there were some clients intrigued 
by the cultural differences between them and their therapists. However, the results of this 
study should be interpreted with caution because of the possible effect of selection bias. It 
 
 22 
 
is likely that clients who chose to complete the survey had either particularly positive or 
negative experiences with their non-native English-speaking therapists, whereas those 
clients who had negative experiences with their non-native English-speaking therapists 
simply decided not to participate in this study. 
Mittal and Wieling (2006) conducted a qualitative study to examine international 
students? experiences in Marriage and Family Therapy doctoral programs in the US. 
Thirteen international individuals (8 students and 5 program graduates) were recruited 
using a nonrandom, purposive sampling method from seven accredited PhD programs. 
The countries of origin of the participants were india (4), Mexico (2), Malaysia (2), 
Germany (1), Canada (1), Japan (1), Iran (1), and South Africa (1).While 15% of 
participants reported English as the first language, the primary language of nearly half of 
the participants was not English. About 38% of participants considered themselves as 
either bi- or trilingual. Five participants came to the US for undergraduate and/or 
Master?s degrees and then moved on to their PhD program, while the other five had been 
to the US earlier in their lives. Participants were interviewed for 1.5 to 2 hours either in 
person or via phone (One participant who was living outside of the US was interviewed 
via email with the same set of questions). Interviews were semi-structured and focused on 
participants? experience in MFT programs in terms of theory, research, clinical training, 
supervision and practice.  
In Mittal and Wieling (2006), the first author analyzed all data, while the second 
author served as the auditor. The data analysis followed a modified van Kaam method, in 
that the first author listed all expressions that were relevant to the experience under 
investigation, and then reduced and eliminated expressions that were repetitive. Then the 
 
 23 
 
author created themes from the nonrepetitive, nonoverlapping clusters of meaning, and 
integrated the themes for each participant to create individual textual descriptions. The 
author then collapsed and reanalyzed individual textual descriptions iteratively until the 
most salient or essential themes for all participants were developed. The author also 
summarized and reported perspectives that were essential within the context of 
individuals? experiences even if these perspectives were only reported by a small number 
of people. Throughout the research, the first author kept a reflective journal to record the 
process of the study and her thoughts and feelings. 
 Mittal and Wieling?s (2006) results were organized into several categories: 
experiences related to perceptions of aspects of one?s self, experiences related to 
relationships with systems external to self, and strategies that helped international 
students to cope. Under the category of experiences related to perceptions of aspects of 
one?s self, several participants reported struggles with regard to being outsiders to the 
US, such as the feeling of inferiority to US nationals, and worries about their apparent 
differences, as well as how clients might react to them. Participants also reported anxiety 
due to lack of English proficiency. Specifically, six participants struggled with speaking 
in English, and difficulties in speaking up in class. 
 Under the category of experiences related to relationships with systems external to 
self, four participants reported being pushed to learn and practice American values. Two 
students reported negative feelings toward the pressure, whereas another two discussed 
positive aspects of the pressure. Several participants reported experiences with covert and 
overt racist and discriminatory attitudes from clients. One participant reported ?being 
careful? about things she said in conversations with her client initially, and she reported 
 
 24 
 
that a few clients refused her services because of her background as an international 
trainee. 
 Under the category of strategies that helped international students to cope, 
participants identified three main strategies: learning to be more confident about one?s 
difference, learning to stand up for oneself, and having a nonquitting attitude. In terms of 
learning to be more confident about one?s difference, one participant reported that she 
talked with her clients about her differences in therapy, whereas another participant 
shared that she was more at ease with clients refusing her services because of her 
nationality than she had been at the onset. In addition, two participants stated that they 
had developed their own strategies to deal with their difference during conversations with 
clients. In terms of learning to stand up for oneself, five participants reported being more 
direct and explicit with either faculty or supervisors about their needs and differences. In 
terms of having a nonquitting attitude, two participants reported completing their 
programs through their strong wills after faculty suggested them to leave the program 
because of difficulties the faculty felt the students were facing or might face.  
Mittal and Wieling (2006)?s thorough investigation of the experience of 
international MFT trainees shed light on some challenges that international trainees 
encounter when they conduct therapy in the United States, and how international trainees 
cope with these challenges. However, the authors did not explore these challenges facing 
international trainees in depth. For instance, although the authors identified the pressure 
to practice American values, they did not explore how this pressure and international 
trainees? reactions to the pressure might play out in international trainees? interactions 
with their clients.  
 
 25 
 
Ng (2006b) surveyed 37 counseling educators from CACREP-accredited programs 
on their perceptions of and experiences with international trainees. The results were that 
counseling educators perceived that non-western international trainees experienced more 
problems than both western international trainees and American trainees in English 
proficiency, difficulty in clinical courses, and conflict with Western understanding of and 
approaches to treating mental illness. However, the three groups (i.e. American trainees, 
Western international trainees, and non-Western international trainees) did not differ in 
terms of academic problems, mental/emotional distress, social/relational problems with 
peers, problems fitting into clinical placements, or mentoring by faculty members. The 
majority of participants perceived that the impact of international trainees on them and 
their programs was positive. In addition, the majority of participants agreed that 
international trainees should be treated as a separate group that is qualitatively different 
American trainees. Participants could not reach consensus on whether international 
students needed accommodations to succeed. In terms of the assistance provided to 
international trainees, nearly 90% of participants reported providing academic 
accommodations to international students, such as allowing resubmission of written 
assignments, providing more time to complete assignments, requiring additional reading 
and writing classes, and providing one-on-one mentoring to deal with academic concerns. 
Only 11% of participants encouraged international students to choose class assignments 
or projects relevant to their cultures. The findings of this study suggest that clinical work 
received less attention from educators than academic work.  
In sum, the existing literature on international trainees in mental health training 
programs focused on examination of training experience in general. Several studies 
 
 26 
 
touched on some unique aspects of international trainees that may affect their experiences 
of working with clients. For instance, it has been found that English proficiency affects 
international trainees? anxiety levels and clinical skills (Chen, 2004; Mittal & Wieling 
,2006; Ng, 2006). However, clients do not consider having a non-native English Speaking 
therapist as hindering to or even important for their therapy experience (Morris & Lee, 
2004). In addition to struggle with language, international trainees typically experience 
conflict between their cultures of origin and the mainstream theories of western 
therapy/counseling (Mittal & Wieling, 2006; Ng, 2006; Pattison, 2003). Another 
challenge for international trainees is that they often worry about how their clients 
perceive them, and sometimes experience overt or covert discrimination from their clients 
(Mittal & Wieling, 2006). In terms of the within-group difference among international 
students, counseling educators perceive that non-western international students struggle 
more with both language proficiency and cultural conflicts than do western international 
trainees. 
Several factors have been identified as facilitative to international trainees? learning. 
Chen (2004) found that constructive relationships with fellow trainees, professors, and 
supervisors as well as a training environment that was culturally open-minded and 
responsive to individuals? training needs were helpful for international trainees. In 
addition, Mittal and Wieling (2006) found that some international trainees coped with 
clients? discrimination by either discussing cultural differences with clients or learning to 
be more at ease with clients refusing their services. International trainees also coped by 
becoming more assertive and direct with faculty/supervisors about their needs and 
differences.  
 
 27 
 
Although previous studies shed light on international trainees? experience of doing 
therapy, none of these studies was conducted on international counseling students who 
received their training in the United States. In addition, the samples of these studies are 
rather heterogeneous, particularly in terms of the cultural backgrounds of participants.  
Furthermore, the exploration of international trainees? experiences of doing therapy in 
these studies lack depth. For instance, although cultural conflicts have been noted in 
several studies (Mittal & Wieling, 2006; Ng, 2006; Pattison, 2003), the impact of cultural 
conflicts on international trainees? clinical work has not been explored.  
The Impact of Collectivistic Culture on Therapy Process 
In this section, I review studies that shed light on cultural conflicts that may be 
experienced by East-Asian international trainees. Because eastern Asian countries are 
generally dominated by collectivistic culture (Triandis, 1995), while western counseling 
theories and practice are rooted in individualistic culture (Pederson, 2003), I focus on 
how individualism/collectivism may affect therapy process. Specifically, I start with a 
review of cross-cultural psychology literature that examines how 
individualism/collectivism affects individuals? self-concept, cognition, and emotion. 
Then I conceptually discuss how the findings from cross-cultural psychology may inform 
us on the influence of individualism/collectivism on therapists? experiences of doing 
therapy. 
Markus and Kitayama (1991) proposed that culture (individualism vs. collectivism) 
affects individuals? self-concept, such that individuals from individualistic cultures tend 
to develop independent selves, whereas those from collectivistic cultures tend to develop 
interdependent selves. Individuals with independent selves focus on internal, private 
 
 28 
 
attributes, such as abilities, thoughts, feelings, whereas individuals with interdependent 
selves focus on external and public features, such as status, roles, obligations, and 
relationships. The primary tasks for the independent self is to promote autonomy, express 
oneself, realize one?s internal attributes and promote one?s goals, whereas the tasks for 
the interdependent self is to seek connectedness, fulfill one?s obligations, engage in 
appropriate interactions, and promote group?s goals. The self-esteem of individuals with 
independent selves derives from their abilities to express themselves and the validation of 
their internal attributes; whereas the self-esteem of individuals with interdependent selves 
come from their abilities to restrain themselves and to maintain harmony in the social 
context.  
Markus and Kitayama (1991) then discussed the effects of the two different self-
 concepts (i.e. independent and interdependent sele) on cognition, emotion, and 
motivation. In terms of the effect on cognition, the authors hypothesized that those with 
interdependent selves would be more attentive and sensitive to others than those with 
independent selves. In addition, for those with interdependent selves, knowledge about 
persons, either the self or others, would remain specific to the focal context. In terms of 
the effect on emotion, individuals with interdependent selves might experience and 
express other-focused emotions (i.e. shame or sympathy) more frequently than 
individuals with independent selves. In contrast, individuals with independent selves 
might experience and expresse ego-focused emotions (i.e. pride, anger, or frustration) 
more frequently than individuals with interdependent selves. In addition, the authors 
believed that achievement motivation might be defined differently for people with 
different self-concepts. Specifically, individuals with independent selves tend to be 
 
 29 
 
motivated to achieve some internalized standards of excellence, whereas individuals with 
interdependent selves tend to be motivated to fulfill expectations of significant others.  
Wu and Keysar (2007) conducted a cross-cultural comparison study to examine the 
effect of culture on perspective-taking (defined as considering others? beliefs, goals, and 
intentions to understand their actions). They compared the performance of non-Asian 
American college students in a perspective-taking exercise to the performance of their 
Chinese counterparts. The result showed that Chinese participants were more tuned into 
their partners? perspective than were non-Asian American participants. Specifically, 
Chinese participants made fewer errors in assessing the intentions of their partners, and 
were less distracted by their own private perspectives than were non-Asian American 
participants.  
Oyserman and Lee (2008) conducted a meta analysis of cross-cultural studies on the 
effects of primed individualism/collectivism on self-concepts, relationality, values, well-
 being, and cognition. Their results provided empirical evidence for some hypotheses 
proposed by Markus and Kitayama (1991). The authors reviewed a number of studies that 
were conducted primarily on college students in the United States, Europe, and Asia and 
found that when collectivism was primed, participants? endorsement of collectivistic 
values increased and their endorsement of individualistic values decreased. In addition, 
when collectivism was primed, participants were more likely to embrace the independent 
self than the interdependent self. Furthermore, the authors found that primed collectivism 
led to more focus on social obligation, greater social sensitivity, and higher levels of 
prosocial orientation than did primed individualism.  
 
 30 
 
In sum, studies from cross-cultural psychology suggest that 
individualism/collectivism affects individuals? self-concepts, such that individuals in 
individualistic culture often hold independent selves, while individuals from collectivistic 
culture often have interdependent selves. Individuals with independent/ interdepednent 
self-concept have different values, strive for different goals, and claim their self-esteem 
from different sources. In addition, individualism/collectivism affects individuals? 
cognition, in that people from collectivistic cultures tend to be more attentive and 
sensitive to others? perspectives than do people from individualistic culture (Markus & 
Kitayama, 1991; Wu & Keysar, 2007).  
Because of the differences between individualistic and collectivistic cultures, the 
goals for therapy may be different for therapists from collectivistic cultures than for those 
from individualistic cultures. Specifically, therapists from collectivistic cultures may 
believe that the goal for therapy is to help clients maintain social harmony, whereas 
therapists from individualistic cultures may view the goal of therapy as promoting 
autonomy. In addition, individualism/collectivism may affect therapists? 
conceptualizations of their clients. For instance, therapists from collectivistic cultures 
may pay more attention to the impacts of clients? social networks on clients? problems 
than do therapists from individualistic cultures. In other words, therapists from the 
collectivistic cultures may be more likely to use a systemic framework to conceptualize 
their clients? issues than do those from individualistic cultures. Furthermore, 
individualism/collectivism may influence therapists? use of certain therapeutic 
interventions. For example, it may be more challenging for therapists from collectivistic 
cultures as compared with independent cultures to use challenge or immediacy with their 
 
 31 
 
clients because the use of these two skills seems to go against the cultural rule of 
maintaining harmony for therapists from collectivistic cultures. 
Counseling Psychology in East Asia 
Kasai (2009) briefly introduced culturally shaped concepts of self, and discussed the 
indigenous and adapted approaches to counseling in Japan. The author identified 
Buddhism and Shinto (i.e. a native religion in Japan) as the major religious forces that 
informed Japanese?s sense of self. Both religions emphasized on the union of individuals 
with their environments and the acceptance of one?s environment. In addition, the author 
noted that Confucianism, as the dominant moral-political philosophy of Japan, led Japan 
to become a collectivistic country in which individuals were thought to be embedded and 
situated in particular roles and were encouraged to put other people?s and the group?s 
interests before their own. Under the influence of collectivistic cultural values, the 
boundaries between self and others were perceived to be undifferentiated in Japan. 
Specifically, a willingness and ability to take other?s perspectives, and to help others 
satisfy their wishes and realize their goals were highly valued in Japanese society. 
Maintaining a close relationship with others, particularly with one?s mother, was 
perceived to be socially desirable. Japanese women were encouraged, sometimes 
pressured, to put their career on hold to devote all their times and energy to their children. 
When a Japanese child matured, he/she was encouraged to maintain a close relationship 
with the mothers by pleasing her. Because of cultural differences, the author believed that 
the goals of counseling differed between Japan and western cultures. Instead of pursuing 
personal gratification and forming a clear boundary between the self and others, the goal 
of counseling in Japan was to dissolve the concept of the self and to unite or merge the 
 
 32 
 
self with one?s surroundings. Japanese counselors often helped their clients to achieve 
this goal by helping them focus away from the self and form a strong emotional 
connection with the environment. Two Japanese indigenous approaches to 
psychotherapy, Morita therapy and Naikan therapy, focused on help clients to dissolve 
the concept of self either by accepting their feelings and problems as they were or by 
helping clients to understand what others felt and thought. The author believed the 
transferability of western counseling approaches to Japan depended on the compatibility 
of these approaches with Japanese cultural values. For instance, person-centered therapy 
has been widely accepted in Japan because its emphasis on empathy, acceptance, and 
support was consistent with collectivistic values. In contrast, confrontation was believed 
to be in conflict with the collectivistic emphasis on interpersonal harmony, and often led 
to a Japanese client to passively agree with the therapists to save the therapist?s face.  
C. Kim, D. Kim, Seo, and K. Kim (2009) discussed influential cultural values in 
South Korea, and how these cultural values affected approaches to counseling. The 
authors reported that Confucianism has fundamental and pervasive influence on Koreans? 
values and social behaviors. Specifically, the authors identified several culturally 
desirable behaviors of Korean, including conformity to familial and social norms, 
hierarchical family structure, self-control and restraint of emotional expression, respect 
for authority and elders, and prescribed gender role relationships. The authors believed 
that the core of social relationships in Korea was the pursuit of we-ness, i.e. Korean 
people often strive for a tight emotional bond with others and tend to suppress their 
individual needs for the sake of the tight emotional bond. In addition, the authors stated 
that sensitivity to others? needs, defined as ?an interpersonal ability to read others? 
 
 33 
 
feelings and opinions by observing their nonverbal cues? (p. 178), was an important skill 
in communication with Koreans, given that Koreans often considered withholding direct 
emotional expression and self-control as important virtues. As a result, the authors 
suggested that when working with Koreans, counselors who were able to validate clients? 
experiences were perceived as more empathetic than counselors who were able to explore 
clients? inner feelings. Moreover, the authors noted that saving face, another cultural 
concept, led to Korean?s avoidance of confrontation in counseling. Furthermore, the 
authors reported that Koreans emphasized on interdependence among family members, 
and prescribed roles of family members. Interestingly, the authors cited empirical 
evidence to support that counselors taking parent-like roles, particularly a combination of 
a stern father and an affectionate mother, was one of the therapeutic common factors that 
led to positive outcomes with Korean clients.   
Hwang and Chang (2009) briefly reviewed concepts of self derived from three 
influential philosophies (i.e., Confucianism, Taoism, and Buddhism) that have pervasive 
impact on Chinese societies, and highlighted the different goals of self-cultivation 
according to the three philosophies. The authors, then, discussed the therapeutic functions 
of self-cultivation within the context of Confucianism, Taoism, and Buddhism. 
According to the authors, in a Confucian society, self is viewed as relational in the sense 
that an individual is perceived as embedded in a particular social network and a sense of 
self is defined by one?s social roles and obligations to others. Each individual is expected 
to take into consideration others? expectations when interacting with others, and to fulfill 
obligations in relationships, particularly to family members. As a result, the goal of self-
 
 34 
 
cultivation is to become a morally upright person, and the mean of self-cultivation is to 
follow the rules of proper conduct and to work hard to strive for socially approved goals.  
According to Hwang and Chang (2009), Taoism is viewed as complementary to 
Confucianism. Taoists believe that ?every element in every system of the universe is 
composed of two opposing components, yin, and yang. These two components are kept in 
balance by the operation of qi? (p.1012).the ideal of Taoists is to maintain balance 
between individuals and Nature, among individuals, and within each individual. 
Individuals are encouraged to emancipate one?s self from the ethical bounds of the world 
and to follow the way of Nature. The goal of self-cultivation is to return to authentic self 
that is a state just like a newborn baby free from all ethical bounds. The Chinese Taoist 
cognitive therapy is a therapy approach that incorporates Taoist philosophy to cognitive 
therapy. The Chinese Taoist cognitive therapy consists of five steps. In the first step, the 
therapist help client to identify and analyze actual stressors based on his/her subjective 
experiences rather than the number of stressful events. The second step requires the client 
to distinguish his/her needs from societal expectations, and to prioritize his/her needs. In 
the third step, the therapist helps the client to evaluate the effectiveness of client?s coping 
strategies in coping with psychological conflicts. During the fourth step, the therapist 
educates the client on the complementary roles of Taoism and Confucianism, and 
discusses with the clients on the meanings and application of a 32-character Taoist 
philosophical teaching. In addition, the client is encouraged to read Tao-Te Ching, a 
classic book on Taoism, to achieve deeper understanding of the Taoist philosophical 
tenets and to change his/her coping strategies based on the Taoist teachings. In the last 
step, the therapist and the client evaluate the effectiveness of the new coping strategies. 
 
 35 
 
The authors reported empirical evidence to support the long-term (i.e. after 6 month) 
effect of the Chinese Taoism cognitive therapy in treating the General Anxiety Disorder. 
 According to Hwang and Chang (2009), the ideal of Buddhism is Buddha. Any 
human being who is enlightened with the teachings of Buddhism may become a Buddha. 
Buddhism encourages people to learn to become a Buddha by practicing Buddha?s way 
of kindness and mercy. In terms of happiness and suffering, Buddhists believe that 
sufferings result from desires and striving for things such as wealth, fame, approval, 
power, and control, etc. Happiness and lasting contentment can be cultivated through 
mindfulness, concentration, and detachment from one?s desires. The goal of self-
 cultivation, according to Buddhism, is to achieve nonself which is a state in which one is 
detached from this world, particularly detachment from holding on to one?s self-concept. 
The authors also discussed two therapeutic techniques rooted in Buddhism: meditation 
and conceptual therapy. Specifically, Buddhist meditation stressed mindfulness, 
awareness, vigilance, and observation in everyday life for the purpose of helping people 
to live in the present and attend to the activity they are engaged in at the moment. 
Conceptual therapy encouraged therapists to use Buddhist stories to help clients to realize 
that sufferings resulted from their desires and to help clients to change their way of 
thinking, feeling, and acting.  
Chen (2009) discussed an indigenous model of counseling to address the cultural 
conflicts that many people in modern Chinese societies might experience. The author 
recognized that Chinese in modern societies often experience conflicts between 
traditional Chinese values (particularly Confucians values) and western values due to the 
rapid modernization and globalization of Chinese societies. It was also proposed that 
 
 36 
 
contemporary Chinese might have a dual self that incorporate characteristics of both an 
independent self and an interdependent self. The independent self focused on pursuing 
personal goals, while the interdependent self emphasized on fulfilling the role obligation, 
developing interpersonal bonds, and maintaining social harmony.  ?When these two 
aspects of self were able to coexist harmoniously, the individual is living in a state of 
psychosocial homeostasis? (p. 998). However, when the two aspects of self were in 
conflict, emotional and interpersonal disturbances might arise. In addition, the author 
stated that the salience of the two aspects of self varied depending on the nature of a 
specific interpersonal relationship. For instance, the interdependent self might be more 
likely to operate in dealing with family relationships (i.e. parent-child relationship, 
sibling relationship, or marriage) or family-like relationships (i.e. close friendships, 
teacher-student relationships); whereas the independent self might be more dominant 
when dealing with nonfamily relationships (i.e. relationship with strangers). Given the 
coexistence of the two aspects of the self, the author proposed that the goal for counseling 
contemporary Chinese was to help clients to develop self-coordination ability to negotiate 
the conflict arising from pursuit of personal development and social harmony. According 
to the author, self-coordination was defined as a behavior that an individual constantly 
and consciously juggles among the tasks of pursuing personal goals, fulfilling role 
obligations, and meeting significant others? expectations in various situations in order to 
maintain harmonious social relationships. It required individuals to become aware of their 
personal needs, role obligations, and elements of interpersonal interactions (i.e. mutual 
goals and others? perspectives). In addition, the author identified four primary tasks of 
counseling that would help clients to achieve the goal of counseling: increasing self-
 
 37 
 
awareness and self-understanding of personal goals, coordinating the self with related 
others (i.e. recognizing one?s role obligations and avoiding direct confrontation in 
interpersonal conflicts), employing multiple conflict resolution strategies (e.g., examining 
the conflict from the other person?s perspectives, openly discussing differences the cause 
the conflict, finding mutual goals and benefits, preparing oneself to compromise, being 
assertive about one?s personal goals, etc.), and managing unmet personal needs and 
distress through self-cultivation, acceptance, and endurance. 
In summary, counseling psychologists in East Asia believe that counseling/therapy 
in East Asia stems from cultures that are different from western culture, needs to address 
issues that western clients might not face, and may involve strategies or techniques that 
are different from western therapy. They suggest that western approaches of therapy may 
not be applied to East Asian societies, and need to be modified. Although East Asian 
counseling psychologists provide insightful observations on the applicability of western 
therapies to East Asian societies, empirical investigation of this issue is lacking.  
Consensual Qualitative Research 
Consensual qualitative research (CQR; Hill et al., 2005; Hill, Thompson, & 
Williams, 1997) is a method for conducting qualitative research. Qualitative research is 
designed to ?describe and clarify experience as it is lived and constituted in awareness? 
(Polkinghorne, 2005, p. 138). The focus of qualitative research is to study a few 
individuals in great depth to identify patterns of human behaviors. 
In regard to studying human experience, qualitative research methods have several 
advantages over quantitative research methods. Human experience is multilayered and 
complex. Using quantitative methods of data gathering , such as Likert scale measures, 
 
 38 
 
researchers can only gather surface information and are unable to capture the richness of 
human experience (Polkinghorne, 2005). On the other hand, qualitative researchers often 
rely on in-depth interviews to gather data, and are more likely to capture the depth of 
human experience. In addition, human experience is not directly observable but rather 
requires introspection and articulation on the part of the participant. Therefore, the quality 
of data on human experience depends on participants? abilities to reflect on their 
experiences. Qualitative researchers often engage in intense interactions with participants 
during the data-gathering process, and thus are more likely to facilitate participants? 
reflections than do their quantitative counterparts.  
Because the purpose of the present study was to examine participants? experience of 
conducting therapy, I employed CQR to gather and analyze data. In this section, I first 
review the philosophical assumptions of CQR, and then describe the three major steps in 
data analysis in CQR. 
The Philosophical Assumptions of Consensual Qualitative Research 
Hill et al. (2005) described the philosophical stance of CQR as being 
?predominantly constructivist and with some postpositivist? elements (p. 197). Ponterotto 
(2005) discussed the differences between constructivist and postpositivist perspectives. 
Specifically, constructivists believe that there are multiple realities that are socially 
constructed. They also recognize the importance of close interaction between researchers 
and participants in the process of understanding participants? lived experiences. They 
tend to use naturalistic and qualitative methods, and aim at bracketing (i.e. 
acknowledging and describing) researchers? expectations. On the other hand, 
postpositivists believe that an objective, universal truth exists, although they admit that 
 
 39 
 
researchers cannot fully apprehend the absolute truth. They prefer an objective, detached 
researcher role, and encourage researchers to minimize the influence of their expectation 
and biases. They often favor quantitative methods over qualitative methods. 
CQR is constructivist in terms of ontology (i.e. view of nature of reality) and 
methodology (i.e. the process and procedures of research). According to Hill et al. 
(2005), CQR researchers recognize the existence of multiple and equally valid versions 
of ?the truth,? and view reality as being socially constructed. In addition, CQR 
researchers tend to use interactive data collection methods (e.g. semi-structured 
interview) to collect data in a naturalistic setting.   
In terms of epistemology (i.e. researcher-participant relationship) and axiology (i.e. 
the role of researchers? values), CQR lies in between the constructivist and postpositivist 
approaches. CQR researchers recognize the mutual influence between the researcher and 
the participant, and thus it is aligned with constructivist thinking. With respect to the role 
of researchers? values, CQR researchers accept the inevitability of researcher biases, and 
often encourage judges to bracket their expectations and biases (constructivist). However, 
CQR researchers strive to reduce undue influences of researcher biases, and aim at 
reporting participants? experience as close as possible rather than interpreting participant 
statements from the researcher?s perspective. In other words, the goal for CQR 
researchers is to reduce the influences of researcher biases on data analysis, which is 
consistent with postpositivist thinking (Hill et al, 2005).   
With respect to rhetorical structure (i.e. language used in presentation of procedures 
and results), CQR is more at the postpositivist end (Hill et al, 2005). Specifically, data in 
CQR studies are usually presented in third-person. CQR researchers strive for objective 
 
 40 
 
summarization of participants? statements and attempt to identify general themes across 
participants and generalize these themes to the population.  
Four Steps in Consensual Qualitative Research  
The CQR includes four central steps (interview, deciding domains, developing core 
ideas, and cross analysis). I briefly introduce the steps in this section and provide more 
detail in the method section. When conducting CQR studies, researchers often use semi-
 structured interviews to collect information. The second step of CQR is to consensually 
develop domains (i.e. topics used to group data). Specifically, a team of researchers 
review several interview transcripts and develop a starting list of domains, and then 
modify the initial list as needed. The third step involves developing core ideas by 
consensus (i.e. summarizing participants? statements to provide clarity as well as to 
reduce redundancy and non-relevant information). The fourth step is cross-analysis. 
Researchers generate categories consensually and place core ideas into the categories by 
consensus. Researchers then label each category (i.e. general, typical, or variant) based 
on the frequency of occurrence of the category across all cases. External auditors are 
involved in all three steps to help make the data as accurate as possible (Hill et al., 2005; 
Hill, Thompson, & Williams, 1997). 
 
 41 
 
Chapter 3: Statement of Problem 
Although international trainees were enrolled in nearly half of CACREP-accredited 
counseling programs and represented 9% of the total enrollment of graduate trainees in 
those programs (Ng, 2006a), empirical investigation of this group of trainees is scant. 
Only three empirical studies have been conducted to explore the training experience of 
international trainees in mental health programs, and no empirical studies have been 
conducted to examine international trainees? experience of doing therapy. In addition, 
although the three existing empirical studies have touched on some aspects of the 
experiences of international trainees that may affect their work with clients, these studies 
share several limitations. First, none of these studies were conducted on international 
counseling students who received their training in the United States. Second, the 
exploration of international trainees? experiences of doing therapy lacked depth in these 
studies.  
To broaden our understanding of international counseling trainees and to address 
some limitations of previous studies, I focused on examining East-Asian international 
counseling trainees? experience of doing therapy in the United States. Specifically, the 
following research questions were addressed.  
Research Question 1: What challenges do East- Asian international trainees face 
during counseling sessions?  
Previous research of international students? training experiences have suggested that 
international trainees experienced challenges in their clinical work, such as anxiety 
associated with perceived English deficiency (Chen, 2004; Mittal & Wieling ,2006), 
cultural conflict (Mittal & Wieling, 2006; Ng, 2006b; Pattison, 2003), and concern about 
 
 42 
 
being discriminated by clients (Mittal & Wieling, 2006). By asking international trainees 
their perceived challenges, I explored what challenges East-Asian international trainees 
may face when they work with their clients.  
Research Question 2: How do East-Asian international trainees cope with those 
challenges? 
Mittal and Wieling (2006) found that international trainees coped with clients? 
discrimination by either discussing cultural differences with clients or learning to be more 
at ease with clients refusing their services. In the present study, I expanded their study 
and asked participants how they coped with all kinds of clinical challenges during and 
between sessions. In addition, I asked participants what factors had helped them to better 
cope with clinical challenges. 
Research Question 3: How do East-Asian international trainees? cultural 
backgrounds affect counseling process?  
Several studies indicated that international trainees typically experienced conflict 
between their cultures of origin and the mainstream theories of western 
therapy/counseling (Mittal & Wieling, 2006; Ng, 2006; Pattison, 2003). Literature from 
cross-cultural psychology also suggested that culture (e.g. individualism/collectivism) 
affected individuals? self-concepts, cognition, emotion, and motivation (Markus & 
Kitayama, 1991; Oyserman & Lee, 2008;Wu & Keysar, 2007). By asking East-Asian 
international trainees about specific cases in which their cultural backgrounds 
facilitated/hindered their work with clients, I explored how international trainees? cultural 
backgrounds affect their case conceptualizations of and interaction with clients.  
 
 43 
 
Research Question 4: What aspects of clinical training that East Asian international 
trainees receive in the US are helpful or need to be improved? 
As noted earlier, the literature on international trainees? experience is scarce, and the 
existing research mainly focused on examining international trainees? overall training 
experience rather than their clinical training (Chen, 2004; Mittal & Wieling ,2006; Ng, 
2006b). The current study examined East-Asian international trainees? experience with 
clinical training by asking them to reflect on and describe what aspects of their clinical 
training were helpful or need to be improved.   
 
 
 44 
 
Chapter 4: Method 
Design 
In this study, semi-structured interviews were used to gain an understanding of East-
 Asian international trainees? experiences of conducting therapy in the U.S. The data were 
analyzed using consensual qualitative research (CQR; Hill et al., 1997; 2005). Thus, the 
design of the current study was a qualitative field study. 
Participants 
Interviewees. Thirteen potential participants were invited to participate in the 
current study and 10 of them agreed to participate (the response rate is 77%). 
Interviewees of the present study were 10 East-Asian international students (9 female, 1 
male; 4 Chinese, 2 Korean, 2 Japanese, & 2 Taiwanese) who were enrolled in doctoral 
programs in counseling psychology in 2011. The age of participants ranged from 25 to 40 
(mean = 29.7, SD = 4.4).  All participants moved to the United States after the age of 18, 
and on average have lived in the United States for 5.48 years (ranging from 2.5 to 10 
years).  The number of years of supervised clinical experience working with adult clients 
in the United States ranged from 2 to 7.5 (mean = 3.8, SD = 1.93). Half of the 
participants (5 out of 10) indicated that they had received training in counseling in their 
home countries. 
When asked to rate the degree to which they believe in and adhere to the techniques 
of various theoretical orientations on a 5-point scale (5 = completely), participants rated 
humanistic/ experiential/ existential approaches 3.6 (SD = 1.35); psychodynamic/ 
psychoanalytic/ interpersonal approaches 3.4 (SD = 0.97); behavioral/cognitive-
 behavioral approaches 2.7 (SD = .67); feminist/ multicultural approaches 4 (SD = .67), 
 
 45 
 
and family/system approaches 2.7 (SD = 0.95). Participants rated the statement ?I intend 
to see clients as part of my future career? 4.4 (SD = 0.84; 1 = strongly disagree; 5 = 
strongly agree). In terms of participants? intention to go back to their home country to 
practice therapy, participants rated 2.9 (SD = 1.52) on a 5-point single-item scale with 5 
indicating the strongest intention to go back to home country to practice therapy.  
On average, participants scored 3.44 (SD = 0.81) on the Collectivism subscale of the 
Asian American Values Scale-Multidimensional (AAVS-M; Kim, Li, & Ng, 2005), a 7-
 point scale assessing the extent to which participants adhere to collectivistic values (1 
indicating the least adherence to collectivistic values and 7 indicating the most adherence 
to collectivistic values). The mean score of the Collectivism subscale of the Asian 
American Value Scale of the current sample (3.44) is lower than the mean score of a 
sample of Asian American college students (4.23), suggesting that a group of Asian 
American college students who grew up in the United States adhered more to 
collectivistic cultural values than did participants of the current study.  
Judges. The primary research team included a 30-year old, female East-Asian 
international advanced doctoral student in counseling psychology and four post-
 baccalaureate individuals (1 male, 3 female; 1 Caucasian, 1 Hispanic, 1 Asian American, 
and 1 African American; age ranging from 23 to 25). In addition, two female doctoral 
students in counseling psychology (one 23-year-old Asian international, one 30-year-old 
Caucasian) participated in the first half of the coding process as judges. All members of 
the research team had completed courses in Helping Skills and Introduction to 
Counseling Psychology or their equivalents. The judges were responsible for transcribing 
the completed interviews and served as part of the data coding team. As recommended by 
 
 46 
 
Hill et al. (1997), efforts were made to ensure that members of the research team got 
along, were committed to and involved in the process, negotiated differences effectively, 
and addressed power issues openly. Specifically, the advanced doctoral judge remained 
sensitive to group dynamic, ask post-baccalaureate judges? opinions before giving her 
own opinion, and encourage post-baccalaureate judges to bring up power issues. In 
addition, all judges were required to read Hill et al. (1997) and Hill et al. (2005) to 
familiarize themselves with CQR process. 
 Prior to starting the coding process, all judges were required to write and discuss 
their biases or expectations about the results of this study in order to ?bracket? them.  In 
terms of challenges that international trainees might encounter, all judges expected that 
East-Asian international trainees would experience language barriers (e.g., difficulty 
understanding dialects or expressing their thoughts in a clear manner). Two judges 
mentioned that they expected international trainees would have difficulty understanding 
American cultures or social norms in the US. Two judges expected East-Asian trainees to 
struggle with internal conflicts due to the difference between collectivistic and 
individualistic cultures, and one judge anticipated that participants would experience 
cultural transference from their clients.  
In terms of coping strategies, four judges mentioned that international students 
would seek support from their international/American peers when encountering 
challenges. Two judges expected East-Asian international trainees to use self-reflection 
or self-examination as coping strategies. One judge anticipated East-Asian trainees to 
avoid thinking about challenges they face, while another judge expected participants to 
cope with challenges through cognitive reframing.  
 
 47 
 
In terms of how East-Asian international trainees? cultural backgrounds may 
affected their work with clients, three judges anticipated East-Asian trainees? cultural 
background would affect how easy to build rapport with their clients, depending on the 
clients? multicultural experience. Specifically, they all expected that it would be easier for 
East-Asian trainees to build rapport with clients with more multicultural experience. Two 
judges expected East-Asian international trainees would have difficulty using certain 
skills, such as immediacy or challenges. Another two judges anticipated East-Asian 
trainees to struggle with confronting elders due to the cultural norm of respecting elders. 
One judge mentioned that he expected that East-Asian international trainees would pay 
more attention to clients? family backgrounds than their American counterparts.  
In terms of the East-Asian international trainees? training experience in the US, all 
judges anticipated that East-Asian trainees would found training in counseling 
theories/skills helpful. Two judges expected that East-Asian trainees would want more 
discussion that is culturally relevant to them in their training experience. 
When bracketing their biases, two judges reported being religious and mentioned 
that they might attribute people?s behaviors, values, or beliefs to their religious 
affiliations rather than their cultural backgrounds. Five judges had prior experience of 
living abroad, and discussed how these experiences might shape their views on 
living/studying abroad. Specifically, all five judges perceived studying/living abroad as 
both challenging and rewarding, and believed that these experiences enriched their life.   
Auditors. The external auditor for this study was the chair of the dissertation 
committee, a 61-year old European-American female faculty member with extensive 
 
 48 
 
experience in CQR and therapist training. The auditor remained separate from the 
primary research team and reviewed the judges? coding process.  
Measures 
Demographicquestionnaire. Participants were asked to indicate their age, gender, 
country of origin, type of graduate program (doctoral vs. master), specialty area (clinical 
vs. counseling), settings in which they have seen clients (university counseling center, 
university mental health center, community mental health center, hospitals, other), 
number of years living in the United States, number of years seeing clients in the United 
States, degree of endorsement (1 = not all; 5 = completely) of humanistic/ experiential / 
existential, psychodynamic/ psychoanalytic/ interpersonal, behavioral/ cognitive-
 behavioral, systemic/ family, and feminist/ multicultural theoretical orientations, the 
degree to which they agree with the statement ?I intend to see clients as part of my future 
career? (1 = strongly disagree, 5 = strongly agree), and the degree to which they agree 
with the statement ?I plan to go back to my home country to practice counseling? (1 = 
strongly disagree; 5 = strongly agree). In addition, participants were asked to write a brief 
description of their previous training in counseling/therapy.  
The Collectivism subscale of the Asian American Values Scale-
 Multidimensional (AAVS-M; Kim, Li, & Ng, 2005). The Collectivism subscale of the 
AAVS-M consists of seven items measuring the extent to which participants adhere to 
collectivistic values. For each item, participants gave an endorsement rating on 7-point 
scale ranging from 1 (strongly disagree) to 7 (strongly agree). A reversely scored sample 
item of the Collectivism subscale of the AAVS-M is ?one need not sacrifice oneself for 
the benefit of the group.? Kim et al. reported that the Cronbach?s alpha of the 
 
 49 
 
Collectivism subscale of the AAVS-M ranged from .80 to .86 and that the convergent 
validity of the Collectivism subscale was demonstrated through its positive correlation ( r 
= .38) with the Interdependent subscale of the Self-Construal Scale (SCS; Singelis, 
1994), another self-report measure of adherence to collectivistic culture. In addition, the 
scores of Collectivism subscale of the AAVS-M is not significantly related to social 
desirability. In the present study, I chose the Collectivism subscale of the AAVS-M to 
assess participants? adherence to the collectivistic culture because it is short and more 
reliable than the Self-Construal Scale. Due to the small sample size and the qualitative 
nature of this study, the Cronbach?s Alpha of the sample in the present study was not 
calculated. 
Semi-structured interview. All participants completed two, 1to 2 hour audio-taped 
semi-structured interviews over the phone. All interviews were conducted in English. The 
first interview started with asking participants to describe their cultural backgrounds. 
Then each participant was asked to describe his/her approaches to therapy, to reflect on 
how his/her approach to therapy fit personal and cultural backgrounds, and to discuss the 
transferability of his/her current approach to therapy to his/her country of origin. Then 
participants were asked to reflect on challenges that they face that related to doing 
therapy in the US, and to describe their coping strategies and facilitative factors that 
helped them to cope with these challenges. The second interview began with any 
clarification questions that came up based on listening to the tape of first interview. Then 
participants were asked to give two cases in which their cultural backgrounds 
facilitated/hindered their clinical work.  
 
 50 
 
The interview protocol was developed in three stages. A set of questions were 
initially developed to address the research questions. These questions were then presented 
to two different focus groups of graduate students and faculty members (an advisee 
meeting group and a dissertation-level research seminar). These focus groups led to 
changes in the interview protocol that included dropping a series of questions about 
international trainees? experience with supervision, moving questions about international 
trainees? previous training on therapy to demographic questionnaire, and adding several 
questions about the transferability of clinical training received in the US to international 
trainees? countries of origin. Then, as recommended by Hill and colleague (Hill et al., 
1997; 2005), I conducted three pilot interviews with interviewees similar to participants 
who were recruited for this study (one third-year Canadian male doctoral student who 
was born and raised in East Asia, one first-year Korean female doctoral student who had 
roughly two years of clinical experience, and one pre-intern Chinese female doctoral 
student who had four years of clinical experience). As the result of these pilot interviews, 
the interview protocol was substantially modified. Specifically, several general questions 
about international trainees? experience of doing therapy were dropped because the 
interviewees reported difficulty answering these questions. In addition, several questions 
about international trainees? experience of using specific counseling skills and about their 
countertransference were changed from separate interview questions to probes that the 
interviewer would ask while participants discussing their cases.  
Procedures 
Participant recruitment. Participants were recruited using a combination of 
snowballing, informant recommendation, and listserve broadcasting. A list of East-Asian 
 
 51 
 
graduate students and faculty members who might work with international counseling 
trainees were identified through personal contact, and then I sent an initial email to these 
people to either invite them to participate in this study or to ask them to provide names of 
East-Asian counseling trainees who might be eligible to participate. In the initial email, I 
briefly described the purpose of the study, the benefits and risks associated with this 
study, criteria for participation, and a copy of the interview protocol. In addition, a 
message describing the purpose of the study, the benefits and risks associated with this 
study, and criteria for participation was posted through the listserve of the Asian 
American Psychological Association and the Taiwanese counseling student and 
professional network. 
Interview. Once eligible participants were identified, I sent them an email with a 
copy of the interview protocol, demographic questionnaire, and the Collectivism subscale 
of the AAVS-M attached. Participants were asked to complete the demographic 
questionnaire and the Collectivism subscale of the AAVS-M and to email them back to 
me. Participants were informed that the return of completed demographic questionnaire 
and AAVS-M indicates their consents to participation. After participants agreed to 
participate, the first interview was scheduled at a mutually convenient time, and I 
conducted the interview by phone. At the end of the first interview, the second interview 
was scheduled. After the first interview, I listened to the tape of the first interview to 
determine if there were issues that needed clarification in the second interview. All 
interviews were audio-taped. After each interview, I recorded my impressions of the 
interview and the interviewee, as recommended by Hill et al. (1997). 
 
 52 
 
CQR process. Once interviews were completed, RAs/judges transcribed them 
verbatim, and I checked transcripts for accuracy. To ensure confidentiality, all identifying 
information was removed, including names of interviewees, clients, practicum sites, 
graduate programs, etc. Each interview was assigned a code number.  
Training judges. As recommended by Hill et al (2005), judges read Hill et al. (1997) 
and Hill et al. (2005) to familiarize themselves with the basic concepts and procedure of 
CQR. In addition, judges were asked to read several studies using CQR. 
Bracketing biases/expectations. Before coding began, the research team recorded 
and discussed their biases/expectations about the data in order to bracket them. Biases are 
defined as ?personal issues that make it difficult for researchers to respond objectively to 
the data? (Hill, et al, 1997, p. 539). Each team member wrote down their feelings and 
reactions to the research topic and how their demographic characteristics might lead to a 
set of biases about the research questions. Expectations are defined as ?beliefs that 
researchers have formed based on reading the literature and thinking about and 
developing the research questions? (Hill et al., 1997, p. 538-539). Each team member 
wrote down his/her expectations in regard to each research question. Team members then 
discussed their biases/expectations in a group meeting. Judges were also asked to set 
aside (bracket) their biases/expectations during data analysis, and instructed to openly 
discuss biases that arise during data analysis. The biases and expectations of judges were 
reported in the previous section. 
Addressing power differentials among judges.  In addition to bracketing 
biases/expectations, early meetings of research team focused on creating an atmosphere 
in which all members of the team were comfortable sharing their perspectives in 
 
 53 
 
discussion. As noted by Hill et al. (1997), reaching consensus among members of the 
research team through extensive discussion is an essential feature of the CQR, as CQR 
assumes that multiple perspectives increase our approximation to the ?truth.? Thus, 
creating an atmosphere in which members of research team feel comfortable contributing 
equally to the consensus process is important.  
Developing domains. The first step of CQR involves dividing responses from open-
 ended interview questions into domains or topic areas. The domains/topic areas were 
initially derived from the major topic areas that arose after surveying several of the 
interviews. A start list of domains was created at the first coding meeting.  Once each 
member had independently coded a transcript into domains, the team met to discuss the 
codings of domains for that transcript and reached consensus. A consensus version of the 
coding for that transcript was then created. The consensus version included the domain 
titles and all of the raw data (i.e. excerpts from the interview) for each domain.  
Constructing core ideas. The task of the second step of CQR is to construct core 
ideas (i.e. summaries of the information in each domain for each case). Specifically, each 
research team member read independently all the raw data for a domain, and summarize 
the data into core ideas. Then team members came together to discuss their core ideas 
until consensus was reached. Once the consensus was reached, the core ideas were added 
to the consensus version of the case. According to Hill et al. (1997), core ideas remained 
as close to the participants? words and meaning as possible.  
Auditing of domains and core ideas. Once the team reached consensus on the 
domains and core ideas for a transcript, the consensus version was sent to the auditor. 
The auditor read through the consensus version to determine whether the raw data were 
 
 54 
 
in the correct domain, that all the important materials in each domain were included in 
the core ideas, and that the wordings of the core ideas were concise and reflective of the 
raw data. The auditors then provided suggestions to the research team, and the team 
consensually decided to accept or reject these suggestions. The team sent their changes 
back to the auditor and continued the revision process until all were satisfied that the best 
construction of the data had been reached. 
Once the research team had finished domains and core ideas for all cases and the 
auditors had audited them, a document including all the cases was formulated. This 
document was then used for the cross-analysis. 
Cross-analysis. The purpose of cross-analysis is to determine whether there are 
similarities among the participants in the sample. Team members individually 
constructed categories to characterize themes within the core ideas within each domain 
across cases. They then met as a group to discuss categories until they reached consensus 
on the wording of the categories (Hill et al., 1997; 2005). Then the judges put core ideas 
into one or more categories individually, discussed the placement of core ideas into 
categories in group and reached consensus. Note that a core idea can be put into more 
than one category if the data are about more than one thing. 
Auditing of cross analysis. The auditor reviewed the results of cross-analysis. 
Specifically, the auditor considered the wording/ representativeness of the categories, and 
suggested whether the categories should be collapsed or further subdivided. The 
researcher team then considered and accepted/rejected the auditors? comments. Again, 
the team sent back the revised cross-analysis to the auditor, noting the changes, and this 
 
 55 
 
process continued until all were satisfied that the product was as elegant as it can possibly 
be. 
Reporting the data. Once the cross-analysis was completed, categories were labeled 
to indicate the degree to which they represented the sample. Following the 
recommendations by Hill et al. (2005), the term general was used to label categories that 
included all or all but one of the cases (9 or 10), typical was used to label categories that 
included more than half of the cases up to the cutoff for general (6-8), variant was used to 
label categories that included at least two cases up to the cut-off for typical (2-5). 
Categories that emerge from single cases were placed into a miscellaneous category. 
 
 
 56 
 
Chapter 5:  Results 
The following five domains emerged through the analyses: (1) culture-related 
challenges in conducting therapy in the US; (2) coping with culture-related challenges; 
(3) the impact of participants? cultural backgrounds on therapy in the positive case; (4) 
the impact of participants? cultural backgrounds in the challenging case; and (5) training 
experience in the US. The frequencies and illustrative quotations for categories and 
subcategories of all five domains can be found in Table 1 (located in Appendix E). Each 
of these domains is described in further detail below. 
Culture-Related Challenges in Conducting Therapy  
Perceived distrust/discrimination from clients. Participants generally perceived 
that some of their clients distrusted them or discriminated against them because of their 
cultural backgrounds, and viewed this distrust/discrimination as a challenge that they 
experienced when working with clients in the US. Specifically, participants typically 
reported experiences in which their clients rejected their services because of their status 
as international trainees.  An illustrative quote is, 
One of my clients, when I was in my very beginning doing the practicum in my 
Master?s program, and my client just said very rude, about me. And, she said  
?because you have accent and I don?t like a counselor with accent. So, can I 
change counselor??.. I feel very shocked about that. Even though we can 
communicate well. And my supervisor just watch  my  sessions with this client, 
and my supervisor just advocate for me and just say ?she can understand your 
English, so that shouldn?t be problem?. So, so, even though in the end, we just 
assign her another counselor, but I feel very hurt in that experience.  
 
 57 
 
In addition, participants variantly reported experiencing covert discrimination 
from their clients (e.g., the client made stereotypically negative comments that targeted at 
the cultural group to which the participant belongs). For example, a participant said, 
I would say more covert [discrimination]. Sometimes clients see me as a Chinese 
woman and they would.. I even have a 65 year old female client who said 
something like ?oh, the Chinese woman are blah blah blah? I felt like that was 
directed at me because I am a Chinese woman. Or sometimes they will refer to 
someone else actually Like ?oh that Chinese the other day did some [bad] stuff?.. I 
felt like that was some kind of discrimination. That?s not directly targeted at me, 
but I feel like that?s relevant. Those are more, not like overtly saying you?re 
Chinese, blah blah, but indirectly making some comments that are very 
stereotypical or negative about Chinese. 
Lastly, participants variantly reported experiences in which their clients openly 
questioned their abilities to help them. For example, one participant said,  
Sometimes when the client is very aware of, of the cultural differences, and they 
question my ability to understand them, I try my best but sometimes I feel like 
it?s, it?s really difficult to work with those kinds of clients. I mean they?re 
continuously questioning whether I can understand them, whether I can shed 
some light on their problems or, so I thought that was a challenge.  
Language barrier. Language barrier was another challenge that participants 
generally experienced.  Language barrier manifested itself in several ways. First, 
participants variantly reported that they have difficulty understanding their clients 
because of language barrier ?I think the first thing is the language barrier. Even though I 
 
 58 
 
sometimes sound like a native, like an American, like I grew up here all my life. That?s 
not true. So, there are times when I don?t understand what the client says and I know 
that.?   
Second, participants variantly found their clients responded negatively to their 
accents.  As an example, one participant said, 
 The biggest one would be language barrier, and accent is the obvious one, and 
sometimes clients question my ability to help them or question about my authority 
because English is not my first language and I do have an accent and some people 
worry if I can understand what they are saying, and then?. or there are other 
people who just simply don?t trust anybody with accents, so that?s, that?s been a 
challenge for me. 
Third, participants variantly reported being a non-native speaker of English 
negatively affected their confidence as a therapist, even though they were able to 
communicate with clients well.  For example, one participant said, 
Only thing I feel much challenging here is the like, language. I mean in Korea I 
feel more confident to convey what I?m thinking or sharing my feedback to 
clients. But here I feel less, much less confident of doing that. So, so I mean, I, so 
I, here, I mean what, what is the difference between working in Korea and 
working here, I mean, I try to listen more here than in Korea. 
Lastly, participants variently felt restricted in their abilities to express themselves 
in English. For example, one participant said , 
We know that it?s very important to ask about client?s feelings. ?how do you feel? 
right? But I feel like, not growing up in this country, my way of expressing 
 
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certain things are more limited. Like I know how to ask how do you feel, but 
maybe for an American they might have multiple ways to get at the same thing. 
They might say ?what?s that like for you to feel that way? or ?when that happens, 
what was going on? but then for me, these are all the things I have to learn. Like 
just like I was learning English. This doesn?t come natural for me. So that?s what 
I?m saying language is not just about whether I pronounce correctly, but also the 
expression.  
A Lack of understanding of nuances of American culture. In addition, East 
Asian international trainees variantly reported that they found it challenging to work with 
American clients because they lacked understanding of the nuances of American culture 
(e.g., cultural reference, social norms, values and cultural practice of a specific cultural 
group, etc.).  For example, one participant said, ?I?m not familiar with some American 
cultures like, their high school life, or like their, their childhood or like some like, like for 
example like, some TV show or some movies. I don?t know well about like American TV 
show or like American movies or American?. 
Countertransference due to cultural conflicts. Another challenge that 
participants variantly experienced was countertransference due to cultural conflicts (e.g., 
negative reaction to the client due to the clash between American cultural value and 
participant?s cultural value). For example, one participant shared her culture-based 
countertransference by saying, 
Maybe in East-Asian countries we value the feeling of parents, we need to respect 
our, parents and, elder family members. But in the United States, they don?t even 
have those concepts in their mind. So sometimes when, when I hear their behavior 
 
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is very rude to their parents, or they just take their parents effort for granted, I, I 
just feel very angry about that. So, that, that?s the cultural thing, so, that could 
make me feel very angry?. sometimes I just struggle whether I should stand on 
parent?s side or on my client?s side.  
Discomfort working with clients? emotions. Participants also variantly reported 
feeling uncomfortable working with clients? emotions. An illustrative example is,  
One of the first challenges was for me to focus on emotions. ?In Korea, or in 
most Asian countries, what I understand is that, we don?t usually focus on 
emotions. We talk about our minds, our behaviors, and how to fix the problem, 
and how to work it out. Those kind of things . So, it was really hard for me to 
focus on the emotions because it was really uncomfortable. I felt like, if I go in 
there, the client might not like it, even though it?s our job. 
Inability to meet clients? expectations. Participants? inability to meet clients? 
expectations (e.g., the client wanting advice while the participating not providing that) 
was another challenge variantly reported by participants.  One participant gave an 
example of not being able to meet his client?s expectation, 
 One Asian client was from Canada, was an immigrant to the states. And during 
the session, he always expects me to understand where he came from and how he 
thinks and the way he interpret things. Like, there were a lot of assumptions, like 
?You are Chinese and you are Asian so you should understand what I mean?. And 
I am very uncomfortable about it. I feel like ?we should be more open and 
articulate and expressive of what?s really going on in your mind?. 
 
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Difficulty being direct with clients. Some participants variantly endorsed 
struggling with being direct with clients as a challenge. For example, one participant said, 
?I am trying to challenge my client, but what I do is I paraphrase his sentence, by 
emphasizing on some word and hoping he can identify this word, and you know. I 
thought I was challenging him, but he?s American people, he didn?t recognize it as a 
challenge, but as a reflection.? 
Coping with Culture-Related Challenges: Coping Strategies 
 Seeking support. Participants generally identified strategies that helped them 
cope with culture-related challenges.  First, they generally reported seeking support and 
feedback from their clinical supervisors in order to cope with culture-related challenges. 
For example, one participant reported, 
 I try to, like, get support, seek support from supervisor and colleagues?. I had 
two supervisors last year, and they are also international trainees. So they, yeah, 
they, they know, like those issues very well, so they tried to like normalize it, and 
they share their own experience. And, so they, yeah, they tried to like normalize it 
and give me, much support. And my, and my like other supervisors who is like 
from here, who are from here, they always try to, they are always like, try to listen 
my perspective as an international trainee. So, yeah and also they try to, like, yeah 
they try to value my own like perspective. So yeah they are very supportive.   
Participants generally sought help from colleagues, peers, and/or classmates. In 
fact, a few participants explicitly stated that they sought support exclusively from peers, 
colleagues, or classmates for certain issues. For instance, one participant said that she had 
 
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never discussed with her supervisor about feeling discriminated by her client, because she 
did not feel she could trust her supervisor, 
Interestingly, for the working alliance part and for the look, the discrimination 
part, I actually never discuss with my supervisors. I always discuss with my 
international friends, international peers. I guess the reason why I never discuss 
with my supervisors, that I never trust them they would ever understand my 
experience. But I trust that all my international students can understand what I 
mean and can relate to me. So when I have those challenges, those 
discriminations, or the hard to establish working alliance with my clients, I always 
debrief with my international friends, my cohort and my partner. I feel like they 
can understand me better, they can support me, deal with these kind of challenges. 
In addition to supervisors and peers, participants variantly sought support 
and/feedback from advisors or other faculty members in their program. For example, one 
participant shared her experience seeking support from the instructor of her practicum 
class by saying , 
I?m currently getting my practicum in counseling center, and our practicum 
instructor, she is really amazing. She?s and experienced counselor, so I think she 
is really into feminist theory, so she really respect, respectful and try to, uh, she?s 
really respect. Respect other people?s feelings, thoughts and ideas. I feel pretty 
comfortable asking for help and we kind of discuss the language thing. 
Addressing cultural issues with clients. In addition to seeking support and 
feedback, participants generally worked with their clients to address cultural issues. They 
had several ways of doing this. 
 
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 Specifically, participants typically disclosed to their clients about their 
international status.  For example, one participant said, 
Every time when I talk to my client, the first time, after we talk about 
confidentiality, I always told them that I am an international student, my 
language, English is my second language, so probably there are some language 
difficulties, if they felt like there are some difficulty understanding me just ask me 
to repeat or if I have some problem with understanding them I will ask them 
questions, so I guess now I felt pretty comfortable doing things like these, I do it 
with every client that I have, and then I felt they are more comfortable with it, and 
I am more comfortable with it, and it hasn?t been an issue, at least with the current 
clients I have. 
They also variantly invited their clients to voice discomfort that clients might 
have. One participant said ?I would usually add something like, even though we were 
raised in different countries and different times but there must be something in common, 
so I hope if the way I approach you seems offended or not appropriate, please talk about 
it. Please talk to me about it. I would say that.? 
When participants experienced internal cultural conflicts, they variantly shared 
with their clients about the internal conflicts.  An illustrative example is, 
 [when experiencing internal cultural conflict, if I have really strong feelings 
about it I will be honest with my clients about like how this impact me, I would 
tell them that personally I really value education and be honest with them, and 
normally when I tell them how I feel, it actually feels better for me?I will also 
try to ensure them that I respect their decisions and will help them to make a 
 
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decision for themselves, and I?m sure a lot of people in  their life already telling 
them what their should do and I would hope to not be that person. 
When a client questioned a participant?s ability to help him/her, participants 
variantly offered the client the option of referring him/her to another counselor (e.g., ?I 
tell them, well, we could try working out, and, if you feel like we?re not really 
connecting, and we?re having difficulties, please let me know, so that I could find another 
counselor that you might be happy to work with.?) 
Participants variantly asked clients to explain or elaborate on words that they did 
not understand.  For example, one participant said, 
Recently, [when I hear a word that I don?t understand] I feel more open about 
asking, ?Oh, I hear this interesting term, and I?m not quite understand what you?re 
talking about. Can you explain it to me? Can you help me to understand it 
more??? At the beginning I feel like oh that?s my fault that?s my sin for not 
understanding this word. But right now, I feel more comfortable and I feel like 
asking my client explain a specific thing for me can actually be beneficial for 
them, because it gives them an opportunity to reflect on what they really mean. 
And even explore the cultural meaning behind a specific word or a specific 
phenomenon. It gives them a second chance to think it through to think more 
critically.   
Another variant coping strategy was being more attentive to clients. For example, 
one participant spoke about being attentive by saying, 
I still speak not so good English. But I guess the attitude, the comfortness, the 
working alliance, my expression, my facial expression, and my attitude that 
 
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demonstrates my client, I care about them. And I am fully present in the 
counseling room with them for the hour.  I?m totally stay with them. I think that is 
the most important thing. And I guess because of that, I get a sense that my clients 
also want to work with me at that time. 
Improving English skills. Participants typically reported that they coped with 
language barriers by improving their English through living with Americans or practicing 
English with a native-speaker language partner regularly. For example, one participant 
said, 
I think that I have really pushed myself to improve [English] was maybe the main 
way that I deal with it?. For the next two years I mainly live with Americans, 
families or roommates. Those times were extremely helpful. I would say it?s not 
about how I could say or how fluently I could speak English, but more self-
 efficacy. I think just the ease of being able to? I mean, I continue to make 
mistakes, and I think that I would never ever stop making mistakes about 
speaking English.  But it?s just more the comfort level. I think that comfort level 
helped with my therapy work to stand, I became less self-conscious about what I 
was saying, so I could really get the energy; I have more energy that go to 
listening to my clients. I felt that I was more able to be present with my clients 
because I don?t struggle, I mean, I struggle less internally. 
Using cognitive restructuring. When participants experienced distrust or 
discrimination from clients, they typically tried to use cognitive restructuring to 
normalize or accept these experiences and not take them personally. One participant said, 
 
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This is kind of a reminder for me I should try not to blame my English skills too 
much, because I am a learning counselor, and I don?t have a perfect counseling 
skills, so maybe that was the reasons that clients don?t trust me or don?t come 
back so um, for that?s one part, if something is not going well I try not to blame 
my English skills too much. and the other part is I?m also doing um phone 
counseling, um, crisis hotline, and then there I have a lot of opportunity to 
observe other counselors, they are not professionally trained counselors, but they 
went through trainings, and most of them are native speakers, and even for them  
sometimes I saw they were hung up.  so it happened to me I tend to think oh is it 
because of my accent or what, but knowing this happens to everybody kind of 
gives me a reminder that this happens all the time and sometimes the reason is not 
me. 
Using avoidance. Variantly, participants mentioned using avoidance as a coping 
strategy (e.g., a participant who was afraid of being discriminated by clients because of 
her accent avoided calling clients and contacted them via email).  Specifically, a 
participant said, 
My colleague is also Asian counselor, her client called and requested a different 
counselor because of her accent, and that scares me too and makes me even more 
self-conscious next time when I call a client. So for a long time I switched to 
email [clients] because clients are not going to know like they are going to get, 
they are still going to see my name and probably know I am a foreigner, but it just 
made me feel more comfortable communicating through email. 
 
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Practicing self-care. Participants also variantly indicated that in order to cope 
with culture-related challenges, they engaged in a variety of self-care activities, including 
exercise, seeking personal therapy, and spending time with family/friends. For instance, 
one participant said, ?. . . exercise, take care of myself, and have fun with my friends and 
talk about it talk with my family is very helpful for me, even though they don?t really 
totally understand and I won?t tell them what exactly happened, it?s soothing and 
comforting to talk to them?. 
Coping with Culture-Related Challenges: Facilitative Personal Attributes 
Participants typically perceived adventurous nature and openness to new 
opportunities/challenges as personal attributes that helped them to cope with culture-
 related challenges. For example, one participant said, 
I think, I, personally I like challenges, because I think it gives me like a chance 
that I, can make development, and then I can be growing, so that?s why I like 
challenges. And also, I like, I like to learn, learn like, I like to have new 
experiences. So, whenever I have like some issues or problems I try to think that 
oh it will be a like good chance for me to learn something from that experience. 
So then, those kinds of attitudes, they?re helpful for me to cope with the issues. 
 Participants variantly endorsed perseverance as a facilitating personal attribute. 
For example one participant said ?I think perseverance is helpful for me. My father 
instilled in me that you don?t give up and no matter how hard it is, and you start a goal 
and you know it?s what you want, you stick with it. A quote that I like is, ?You do what 
you have to do to do what you want to do, and that?s what keeps me motivated and keep 
me going.?  
 
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Participants also variantly endorsed optimism as a personal attribute that helped 
them cope with challenges.  For example, one participant said, 
I guess one thing will be that, I try to stay positive. Even though at one of those 
worst moments that I, I cry, and those kinds of stuff, like, sometime later I joke 
about it. And it really becomes laughable because, I realize even though it was 
hard at that time, sometimes it?s just, kind of, ridiculous to see me, making a 
scene of something that isn?t really, really, what is it?a tragic thing. I guess that, 
that could be one of my strengths. 
In addition, participants variantly perceived good interpersonal skills as an 
facilitative personal attribute.  For example, one participant spoke about the importance 
of good interpersonal skills by saying, 
I mean at different settings I care about the people I work with and I took time 
and took the energy to work to get to know them. Not just remember their names 
passing by. I would sometimes get to know them as person, their personal life, 
their kids, their families. Sometimes I share stuff like food or offering help and all 
those I feel like, allow me to have some good relationship with people, I think that 
helped when I encounter difficulties I go to them, I think they are very willing to 
help me out.  
 Finally, participants variantly reported spirituality as a personal attribute that 
facilitated their coping with challenges.  For example, one participant said ?Spirituality. I 
mean, I have religion, I believe in God. So, when I have problem, I pray, so that is 
helpful.? 
The Impact of Participants? Cultural Backgrounds on Therapy in the Positive Case 
 
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Cultural background/experiences facilitated therapy. Several interesting results 
related to the impact of other aspects of East-Asian counseling trainees? cultural 
backgrounds emerged from the data analysis. Specifically, participants? discussion of 
how their cultural backgrounds/experiences facilitated their work with clients in the 
positive case fell into three major subcategories.  First, participants typically indicated 
that similarities between participants? and their clients? cultural backgrounds/experience 
enhanced the therapeutic relationship. For example, one participant shared that her client 
felt more comfortable working with her because they came from the same cultural 
background and spoke the same native language,  
I was brought in [to work with a Chinese international student who is suicidal] 
because of my language skill, my native language is Chinese.  We speak Chinese 
through the whole session, and the client responds real . She feel comfortable 
talking with me, she feel more comfortable talking [in] Chinese, and then I guess 
that?s helpful, she feel that I could understand her and when she said something I 
could respond to her and show that I could understand because I am also an 
international student.  
Second, participants typically reported that their understandings of Asian cultural 
norms helped therapy. For example, one participant spoke about her understanding of 
Asian norm of respecting elders helped her to interpret her client asking her personal 
questions as the client?s attempt to build connection with her and to respond to the client 
in a culturally appropriate way. Specifically, the participant said, 
For the parts when [the client] ask about my age and my marital status, I feel 
comfortable disclose to them. Because I just reframe it as a way that they try to 
 
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know more about me ? and I think that is helpful to build working alliance. I 
don?t get a sense, I don?t feel like I need to analyze further ?why?. I just think 
that?s a general why they try to know more and be more connected with me, to 
find ways to connect with me. So I feel comfortable about sharing those 
information to them?..if a male Caucasian client who ask me how old I am and 
my marriage status, of course I would say, ?Hmm, interesting. Why you asking 
me this question,? and how that related to what we are talking about.? But the 
thing is, they are Asian and the elders, I feel comfortable to self disclose. 
 Third, participants variantly indicated that their acculturation/ bicultural 
experience were helpful. For instance, one participant shared an experience in which her 
own experience of navigating between American and her own cultures helped her to 
understand her client?s struggle from the perspective of acculturation/enculturation and 
allowed her to assist the client to navigate,  
This client is bi-culture too, because she spent some time in the states when she 
was younger. so am I. I adopted some of the American culture. ? she has a desire 
to hold on to her home culture, but she has some beliefs that does not follow her 
home culture norms. And she was upset about that. So like the internal conflict 
that she experience, but when I say ?that?s ok, you know, you can embrace both 
[cultures]? that was such a permission for her, and she was like ?oh wow?. that 
really kind of reduces some of the burden that she felt, because I think at the level 
she felt she could only be one way. If she?s a little bit different from her home 
culture, that?s a betrayal. So she actually does not like part of herself who behave 
or thought differently from those people in her home culture. So for me to relate 
 
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to that [struggle with navigating two cultures] and normalize that it?s okay to 
embrace both cultures, it encourage her to own that part of herself. It seems to be 
a very encouraging message for the client. Definitely seems like she was really 
struck by the feeling that she can do that, she can have both. 
Self-disclosure of P?s cultural background in the positive case. Participants 
typically indicated that they disclosed cultural background/experience to their clients in 
the positive case, and their self-disclosure served a variety of purposes. First, participants 
typically disclosed their cultural background/experience to build connection with the 
client. For example, one participant disclosed her experience with discrimination to build 
the rapport with a client who struggled because he was the only Asian American in a 
predominantly white community.  Specifically, the participant said,  
Well I also lived in the Midwest, when I was a kid I lived in, Illinois, and, there 
were a lot of international students there, but it was still the Midwest, and there 
were a lot of white kids there, and sometimes it did feel like I was discriminated 
there too. Even though I was pretty young. So, I shared that with her [the client]. I 
wanted her to know that I could understand, maybe not all, but some of the 
experience that she went through when she was a kid. 
Second, participants variantly disclosed their cultural background/experience in 
response to clients? inquires. For example, a client who struggled with reconciling 
between her view on environment protection and the dominant view on environment 
protection among her community asked the participant about how people in the 
participant?s home country view environment protection. The participant answered the 
client?s question and disclosed the cultural view in her home culture, ?I think the main 
 
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thing I disclosed was the attitude towards nature and environment in Japan? the client 
knew I am Japanese. Later on the client brought up the culture difference about nature 
and ask me about how nature is viewed in Japanese culture.? 
Finally , participants variantly disclosed their cultural background/experience in 
order to normalize the client?s experience. For example, one participant said ?And so I 
feel like I share, actually I share my culture background, my experiences, and I think she 
was, sounds pretty uh, comforting, for her to know that she wasn?t alone in experiencing, 
you know what happened in her daily life.? 
Discussion of cultural similarities and/or differences. In addition to disclosing 
their cultural backgrounds/experiences, participants typically discussed with their clients 
about how their cultures were different/similar to one another. For example, one 
participant said, 
I would say I ask a lot of questions.  I also would ask straightforward questions, I 
would say ?what does that say about your culture? You?re telling me all this? and 
then she would very directly articulate what that means to her. And I would talk 
about my culture too.  I say ? Yeah, you know, I come from this culture? and I say 
to her ?sometimes in my culture we do these things too, do you feel that they are 
similar?? she would say ?yeah? so actually towards she knows where I come form 
and she actually asks about it. Later when she say that ?you probably know this, 
being a Chinese and blah blah blah? like that and I would say ?yeah? or I would 
disagree so we do engage in a lot of discussions that would relate to our 
backgrounds. 
 
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Comfort in discussing culture. In terms of the comfort level of engaging in 
cultural discussion, participants variantly endorsed that they felt comfortable discussing 
cultural issues with the identified client in the positive case, mainly because they believed 
the discussion of cultural issues would be beneficial to the client. For instance, one 
participant said, 
I felt that I felt very comfortable [discussing cultural issues with C] because I 
think that it, that those kinds of conversations she, like she needed those kinds of 
conversations and I think, yeah having those kinds of conversations would be 
helpful for her, so, so I felt very comfortable?.  In addition, participants tended to 
feel more comfortable initiating discussion of cultural issues as they further 
explored their own cultural background. For example, one participant said ?And 
also, when I gain more insight into my own cultural heritage, I feel more 
comfortable about initiating discussion of culture. 
Cultural discussions were helpful. In terms of the perceived effect of the 
cultural discussion, participants variantly reported that discussion of cultural issues in the 
positive case were helpful, particularly in terms of building connections with their clients 
and/or providing clients with a different perspective. For instance, one participant said, 
I think I sharing my experience of studying abroad and talking about my culture 
background, and also, talking about C?s culture background and like, any 
differences C might face in the future. Those kinds of conversations I think let 
her, let C have more confidence about studying abroad because she like  already 
have those kinds of conversations so she can make her prepared better. So, yeah 
so I think it?s helpful for her. 
 
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The Impact of Participants? Cultural Backgrounds on Therapy in the Challenging 
Case 
Negative effects of culture. Participants indicated two ways in which culture had 
a negative effect on a specific case. First, they generally indicated that their cultural 
values/experience negatively influenced their conceptualization or intervention with the 
identified client in the challenging case. For example, for a client whose name resembled 
a famous musician in the 60s, the participant did not recognize the meaning behind the 
name. Specifically, the participant said, 
Client?s name actually resembles one of the very well-known musicians in 60s, 
but I didn?t know that.  When I told my supervisor and other peers in practicum 
class (what the client?s name was), they were like ?oh, that?s his name?? I was like 
?oh, why you all look so surprised?? People felt like the client used the same name 
(as the famous rock star) spoke something about this person?s personality. But I 
didn?t know cause I didn?t have the context. So yeah, I think that um, kind of 
restricted.   
In addition, participants variantly perceived the identified client in the challenging 
case distrust them or felt uncomfortable working with them because of their international 
status. For example, one participant said, ?A male Caucasian client, he questioned 
whether I could help him because I came from a different cultural background. I was 
feeling kind of uncomfortable working with him because of that?. 
Attempts to address the negative impact of P?s culture. Participants reported 
three different ways that they attempted to address the potential or actual negative effect 
of their cultural value/experience. First, participants variantly disclosed their cultural 
 
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background (e.g., being an international trainee) to the identified client and processed the 
client?s reactions. For example, one participant said, ?So in the first session, I told her I 
am an international student and non-native speaker of English and asked  how is it for her 
to understand me and how does she feel about communicating with me. And, yeah. . . .  
She said It?s more challenging but she could understand me.?  
Second, participants variantly emphasized on the universality of human 
experience and reassured the client of participants? ability to understand the client. For 
example, one participant explained to the client that she could relate to the client on 
experiences that were common and universal across cultures,  
[When the client asked me whether I could understand him], I explained to him 
that there are some common experience across cultures and I could relate to him 
on these aspects. And he was, he was curious. He, he looked more curious about 
how I could understand him in a way than being like ? I can?t trust you because of 
difference in our the cultural background?.. And, after I explained to him, he 
seemed to understand and accept it. 
Lack of cultural discussion in the challenging Case. Interestingly, participants 
typically reported that cultural issues were not discussed in the challenging case, mainly 
because they believed the discussion of cultural issues were not clinically relevant. For 
example, one participant said, ?Cultural issues were not discussed at all, I?d say. The first 
reason is we didn?t have much time. We know that we have limited amount of session 
because I am leaving the site. Second of all, her concern doesn?t really benefit hearing my 
culture background that much?. 
East Asian Trainees? Training Experience in the US 
 
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Helpful components of clinical training in the US. In discussing the helpful 
components of their training in the US, each participant endorsed at least one helpful 
component of clinical training. Participants variantly indicated that training in 
counseling/psychotherapy theories and skills was helpful. For example, a participant 
stated,  ?I think I feel confident with psychotherapy theories, I feel more theoretically 
confident. Yeah I read a lot. I?ve been reading a lot about theoretical approach and so I 
receive a lot of training about different approach, especially in the XX area there are tons 
of professional schools and organizations I can learn from.?  
Variantly, participants mentioned the opportunity to provide therapy/counseling 
to real clients) as a helpful component of their training in the US. For example, one 
participant spoke about the value of practicing counseling with real client, 
I think just having this real counseling experience with real clients is the most 
important aspect of training a therapist. You can read counseling books or articles, 
but it?s not really?a completely different thing to kind of, practice it with real 
people. So I feel really kind of confident and solid about my clinical skills 
because of I have gone through from one setting to another and different levels of 
practicum training...[Practice is] the only way you learn how to, sort of like 
implement different counseling skills, whether it?s micro skills like listening, 
reflecting, providing empathy or something advance like the empty chair or 
guided imagery. ?You are trigger by any clients that you will get to work with. 
You are triggered by different things in different ways or about different things. I 
think those really provide very rich opportunities for you to examine your blind 
spots. You get to see your strengths, but most importantly you get to see your 
 
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weaknesses and areas that you should improve on in order to become a more 
effective therapist.  
Another variant category of helpful components was supervision. For example, 
one participant shared how her supervisor had helped her in building her self-efficacy as 
a therapist, 
I have really benefited from very very good supervisors, and I just cannot imagine 
without them, how different my experience would have been. They have really 
impacted my confidence about just being a therapist in general (and) my 
confidence about speaking English, doing therapy in English. And it has really 
helped me to understand the dynamic between me and someone who is different 
from me, in a clinical setting. 
Participants also variantly endorsed multicultural training/ opportunities to work 
with diverse clients as a helpful aspect of their training. Specifically, they discussed how 
multicultural training has helped them to deepen their awareness of diversity. An 
illustrative quote is: 
I remember before I came to the US, I thought everybody is the same... But then 
when I come to the US, I recognize, Wow, there is so much more to learn about 
multiculture.  And then I recognize that there are diversity in my home country. 
?.So now I am more and more interested in the cultural diversity in my home 
country and will do some more research about that. 
Finally, participants variantly perceived that the support and encouragement from 
their practicum sites/academic programs was helpful.  One of them said,  
 
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People in my program yeah they are very patient and very understanding about 
having international trainees there. so, yeah,  they are very open to having any 
kind of discussion and  often times invited me to have discussion about any 
difficulty referring to culture difference or culture gap or whatever, including my 
acculturation levels, so I really appreciate that. 
Areas in need of improvement in clinical training. In terms of areas of 
improvement in their training in the US, participants typically reported experiencing a 
lack of cultural sensitivity in supervision or in their academic programs. Some 
participants expressed a wish to have more multiculturally-sensitive supervisors/faculty 
members.  As an example, one participant said,  
I would appreciate the professors or the program can really take international 
training seriously and at least they have some experience working abroad or 
teaching abroad. So they would be more aware of international students? needs, 
instead of letting students struggle and advocate for themselves. Especially if they 
just came to the states and they don?t know anything about this mental health 
field. Actually I am the only one in the program that is international. 
East-Asian international trainees also typically indicated that there was not 
enough multicultural training in their academic programs.  For example, one participant 
said, ?If I could see more clients from the same country as me, .. or study a certain 
specific topic related to a specific cultural group in my home country, of course that 
would definitely be more helpful. Or have a seminar specific, study topic related to my 
culture of origin; that would definitely be more helpful for me.?  
 
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Variantly, participants wished that they had had more opportunities to work with 
diverse clients.  For example, one participant said ?Maybe, it?ll be, like, it?ll be better for 
me to have more chance to see like diverse clients, including people from, like, same 
country as me. Yeah.?  
 
 
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Chapter 6:  Discussion 
The purpose of this study was to broaden our understanding of East-Asian 
international counseling trainees? experience of conducting therapy in the US. The author 
interviewed 10 East-Asian international trainees who were enrolled in APA-accredited 
doctoral programs in counseling psychology across the United States, and who had at 
least 2 years of supervised clinical experience providing therapy to adult clients. The 
research team analyzed the transcripts of these interviews using consensual qualitative 
research (CQR). Five domains emerged from the data: (1) culture-related challenges in 
conducting therapy in the US, (2) how trainees coped with culture-related challenges, (3) 
the impact of trainees? cultural backgrounds on therapy with their clients in a positive 
case, (4) the impact of trainees? cultural backgrounds on therapy with their clients in a 
challenging case, and (5) training experiences in the US.  
Given that the domains are roughly equivalent to the research questions posed in 
Chapter 3 (What challenges do East- Asian international trainees face when working with 
American clients? How do East-Asian international trainees cope with those challenges? 
How do East- Asian international trainees? cultural backgrounds affect counseling 
process? What aspects of clinical training that East Asian international trainees receive in 
the US are helpful or need to be improved), but the domains are more descriptive of the 
data that emerged, I discuss the results using the domains generated in the data analyses. 
Then I discuss limitations of the present study. This chapter is concluded by a discussion 
of the implications of the findings for training as well as for future research.  
Culture-Related Challenges in Conducting Therapy in the US 
 
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Some of challenges reported by East-Asian international trainees in the study are 
consistent with challenges endorsed by international trainees in previous studies. For 
instance, participants in this study generally perceived distrust or discrimination from 
their clients. Some participants stated that their clients rejected their services because of 
their international status. Other participants stated that their clients openly questioned 
their abilities to help the clients. There were also participants who discussed their 
experiences with covert discrimination (e.g., a client making stereotypically negative 
comments targeted at the cultural group to which a participant belongs). This result is 
consistent with Mittal and Wieling?s (2006) finding that international trainees who 
enrolled in marriage and family therapy doctoral programs in the US reported 
experiencing covert and overt racist and discriminatory attitudes from their clients. 
In addition, East-Asian international trainees in this study generally identified a 
language barrier as a challenge that they encountered when working with American 
clients. Some participants had difficulty understanding their clients or expressing 
themselves in English. However, the impact of language barrier reported by participants 
in the current study went beyond difficulty communicating with clients in English. In 
fact, several participants in this study reported that being a non-native speaker of English 
decreased their self-confidence as a therapist, even though they were able to 
communicate with clients. This result is consistent with the finding of previous literature 
that English proficiency affected international trainees? anxiety levels and clinical skills 
(Chen, 2004; Mittal & Wieling, 2006; Ng, 2006b). Other participants indicated that their 
accents negatively affected trust-building with their clients. This finding is consistent 
with Lee?s (2013) finding that a speaker?s non-native accent often prompted stereotyping 
 
 82 
 
and discrimination on the listener?s part and led the listener to downgrade the speaker?s 
competence, social status, social attractiveness, personality, and similarity with the 
listener. 
Participants in this study variantly reported that they found it challenging to work 
with American clients because they did not have enough understanding of the nuances of 
American culture. They struggled with understanding cultural references, social norms, 
and values and cultural practices of specific cultural groups. For example, one participant 
shared that a client?s name resembled a famous rock star in the 60s and her lack of 
knowledge of American pop culture prevented her from recognizing the symbolic 
meaning of the client?s name. Similarly, one of the major concerns raised by clients who 
worked with non-native English speaking therapists was that these therapists would not 
understand them because of cultural differences (Morris & Lee, 2004). 
Another challenge that participants variantly experienced was countertransference 
due to cultural conflicts. Some participants had negative reactions to clients because of 
the clash between the two cultures. Especially when clients? presenting concerns related 
to family conflicts, East-Asian international trainees sometimes found themselves 
aligning with the clients? parents rather than the client due to their cultural value of 
respecting and obeying elders. Although international trainees in previous studies did not 
explicitly discuss countertransference due to cultural conflicts, they reported experiencing 
conflict between their cultures of origin and the mainstream western cultures (Mittal & 
Wieling, 2006; Ng, 2006b; Pattison, 2003).  
It is interesting to note that the East-Asian international trainees in this study 
reported several challenges that have not been reported in previous studies of the general 
 
 83 
 
population of international counseling trainees. First, East-Asian trainees felt discomfort 
working with clients? emotions. Several researchers (Kasai, 2009; C. Kim, D. Kim, Seo, 
and K. Kim, 2009; Chen, 2009) have noted that self-control and restraint of emotional 
expression are characteristic of East Asian cultures. It is understandable that East Asian 
counseling trainees in this study experienced discomfort working with clients? emotions 
given that in their cultures of origin, restraint of emotional expression is valued and 
facilitation of emotional expression is likely to be perceived as culturally inappropriate.  
In addition, participants struggled with being direct with clients, which may be a 
result of East Asian trainees having been socialized to communicate in an indirect style in 
high-context cultures. Hall (1976, 2000) found that cultures can be categorized into either 
low-context or high context culture. Specifically, communication occurs predominantly 
through explicit statements or speeches in low context cultures such as American culture; 
whereas messages are often communicated through non-verbal cues such as body 
languages and the use of silence in high-context cultures (e.g.., East Asian cultures). As a 
result, individuals in low context cultures tend to prefer more direct communication, 
whereas individuals in high context cultures prefer indirect communication. 
In sum, several challenges (i.e., distrust/discrimination from clients, language 
barrier, a lack of understanding of cultural nuances, and countertransference due to 
cultural conflicts) endorsed by East-Asian counseling trainees in the current study are 
consistent with findings of previous studies of international trainees from diverse cultural 
backgrounds.  It seems that these challenges are common across international trainees 
from various cultural backgrounds and result from their status of being a foreigner. In 
addition, East-Asian counseling trainees in the present study reported some challenges 
 
 84 
 
that may be unique to their East-Asian cultural backgrounds, such as discomfort working 
with clients? emotions and difficulty being direct with their clients. 
Coping with Culture-Related Challenges  
Coping strategies. East Asian international trainees in the present study generally 
reported that they sought support and feedback from their clinical supervisors, from 
colleagues/peers/classmates, and from advisors or other faculty members in order to cope 
with culture-related challenges. This finding is consistent with the findings of previous 
research that constructive relationships with fellow trainees, professors, and supervisors 
were helpful for international trainees (Chen, 2004).  
In addition to seeking support and feedback, East-Asian counseling trainees in this 
study generally worked with their clients to address cultural issues, which is similar to 
Mittal and Wieling (2006)?s finding that some international trainees coped with 
discrimination by discussing cultural differences with clients. Specifically, participants in 
this study disclosed to their clients about their international status/cultural background, 
shared their own internal cultural conflict with their clients to resolve these conflicts, and 
asked clients to explain or elaborate on words that they did not understand when coping 
with language barrier.  
In addition, East Asian international trainees in the current study typically coped 
with language barriers by improving their English through living with Americans or 
practicing English with a native-speaker language partner regularly. East Asian 
international trainees in the present study perceived improving English skills as helpful, 
which is consistent with the finding that problem-focused coping tends to be associated 
 
 85 
 
with positive outcomes such as positive affect and lowered level of stress (Ben-Zur, 
2009; Lazarus, 1999).  
East Asian international trainees in the current study also typically used cognitive 
restructuring to cope with distrust or discrimination from clients. Participants often 
reminded themselves that even counselors who are native speakers of English have been 
rejected by their clients, which helped them normalize their experiences and not take 
these experiences personally. This result is consistent with Mittal and Wieling (2006)?s 
finding that international marriage and family therapy trainees coped with 
discrimination/rejection by learning not to take it personally. 
Interestingly, East-Asian international trainees in this study admitted that they 
variantly engaged in avoidance behaviors to cope with challenges. Some participants 
avoided calling clients so that clients would not hear their accents and recognize their 
international status. Participants did not seem to be aware of the effects of avoidance 
coping, but previous students on international students? coping have found that the use of 
avoidance was associated with psychological distress (Smith & Khawaja, 2011). 
Lastly, East Asian international trainees in the study variantly engaged in self-care 
activities (e.g., pursuing personal therapy, exercise, spending time with family and 
friends) to cope with challenges. This finding suggested that these students were aware 
that they needed to take care of themselves, which may be a result of the emphasis on 
self-care in the field of professional psychology (Barnett, Baker, Elman, & Schoener, 
2007). 
Facilitative personal attributes. In addition to coping strategies, a number of 
adaptive personal attributes (i.e., openness to new experience, perseverance, optimism, 
 
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spirituality, and good interpersonal skills) helped East Asian international trainees cope 
with challenges. Some of these attributes are aligned with protective factors identified in 
the literature on resilience (i.e., hardiness that involves belief in one?s ability to control 
surroundings and to learn from both positive and negative life experiences, optimism, and 
spirituality; Fletcher & Sarkar, 2013). Hence, even though these East-Asian international 
counseling trainees faced a number of challenges when working with clients in the US, 
they were resilient and resourceful in dealing with these challenges. 
The Impact of P?s Cultural Backgrounds on Therapy in the Positive Case  
Interestingly, when asked to reflect on and discuss a case in which their cultural 
background facilitated their clinical work, all participants chose to talk about a case with 
a client who was either an international student (4 of the 10) or an ethnic minority (6 of 
the 10 were Asian American or African American).  
In addition, although I initially intended to investigate how collectivistic culture 
affected East-Asian counseling trainees? work with their clients, participants of this study 
did not discuss much about the impact of collectivistic values on their clinical work. 
Perhaps this is because participants in the current study had adopted individualistic values 
and thus collectivistic cultural values had become less salient to them. In fact, as noted in 
chapter 4, the mean score of the Collectivism subscale of the Asian American Value 
Scale of the current sample (3.44) is lower than the mean score of a sample of Asian 
American college students (4.23), suggesting that a group of Asian American college 
students who grew up in the United States adhered more to collectivistic cultural values 
than did participants of the current study.   
 
 87 
 
East-Asian trainees? cultural backgrounds facilitated therapy. Several 
interesting results emerged from the analysis about the positive case. First, trainees 
typically reported that the similarities between them and their clients in terms of cultural 
backgrounds/experience enhanced the therapeutic relationship . Participants indicated 
that these clients felt more comfortable opening up because of the participant?s 
background as an international trainee or a member of minority group. One explanation 
for this result comes from social identity theory (e.g., Taifel & Turner, 1986) and self-
 categorization theory (Turner, Hogg, Oakes, Reicher, & Wetherell, 1987), suggesting that 
individuals categorize self and others into in-groups and out-groups. In addition, 
individuals tend to identify with their in-groups (i.e., others who belong to the same 
social group) and engage in competition and discrimination with out-groups (i.e., others 
who do not belong to the same social group) to maintain a distinct and positive social 
identity.  Indeed, research has found that individuals respond more favorably (e.g., 
showing higher level of trust and acceptance) to in-group members and endorse more 
biases toward out-group members (Hornsey, Oppes, & Svensson, 2002; Yuki, Maddux, 
Brewer, and Takemura, 2005).  In the present study, the finding that participants shared 
similar cultural backgrounds or experiences with their clients in the positive cases 
suggested that participants and clients perceived each other as in-group members and thus 
the therapeutic relationships with these clients were enhanced.  
Second, East-Asian international trainees in the present study typically reported that 
their understanding of Asian cultural norms enhanced their clinical work with clients. 
Participants suggested that their knowledge of Asian cultural values helped them to 
understand their clients? behaviors (e.g., an inquiry about personal information) within 
 
 88 
 
the context of Asian cultures and to respond to their clients in a culturally sensitive way. 
This finding offered preliminary evidence to support the proposition that a therapist?s 
multicultural knowledge (i.e., the understanding of clients? cultural experience and 
worldview) facilitates therapy. Thus, these trainees were multiculturally competent with 
these positive cases, given that they responded sensitively to them. Although the concept 
of multicultural competence proposed by Sue and colleagues (Sue et al., 1982; Sue et al., 
1992) has been widely used and has stimulated a great deal of empirical research, 
counseling psychologists cannot reach consensus on whether multicultural competence is 
linked to positive counseling outcome (Owen, Leach, Wampold & Rodolfa , 2011; 
Worthington & Dillon, 2001). The result of the current study suggested that multicultural 
competence was an important factor in the success of the cases at least in the eyes of 
East-Asian international counseling trainees. 
Lastly, East-Asian international counseling trainees variantly indicated that their 
acculturation/bicultural experience helped their work with their clients in the positive 
cases. Participants noted that their experiences navigating between American and East 
Asian cultures helped them recognize how acculturation had contributed to clients? 
problems and thus were able to provide the clients with a different perspective about their 
acculturative stress. This finding is aligned with a growing number of studies on the 
positive effect of biculturalism. In Nguyen and Benet-Martinez?s (2013) meta-analysis of 
83 empirical studies, they found a significant, strong, and positive association between 
biculturalism and psychological adjustment, which they attributed to the possibility that 
having bicultural experience enhances cognitive and social flexibility. In addition, 
Maddux and Galinsky (2009) found that bicultural experience (i.e., living abroad) 
 
 89 
 
increased creativity. Although the impact of counselors? bicultural experiences has not 
been studied, the result of the current study suggests that bicultural experiences can be an 
asset to clinical work.  
Self-disclosure and cultural discussion in the positive case. Participants typically 
disclosed their cultural backgrounds and discussed cultural issues openly with clients to 
build connection with clients, respond to clients? inquiries, and normalize clients? 
experiences. Participants probably felt more comfortable with these clients, which helped 
them disclose, which in turn enhanced the outcome. This result is consistent with Hill and 
Knox?s (2002) findings that therapists were likely to disclose to increase perceived 
similarity between themselves and their clients, model appropriate behavior for clients, 
foster the therapeutic alliance, normalize client experiences, offer alternative ways of 
thinking and acting, and satisfy clients who wanted therapist disclosure. In addition, the 
authors concluded that clients often rated their therapists? self-disclosures as helpful and 
reassuring, and that disclosure had a positive impact on therapeutic relationships.  
The Impact of P?s Cultural Backgrounds on Therapy in the Challenging Case  
When asked to discuss a case in which participants? cultural background hindered 
their clinical work, all the participants discussed cases with clients who were very 
different from them (7 out of 10 clients were White, 3 of 10 from different SES 
backgrounds).  
East Asian trainees? cultural backgrounds negatively impacted therapy. 
Participants generally indicated that their lack of understanding of American cultural 
nuances negatively influenced their conceptualization and /or intervention with these 
clients. Not understanding American pop culture prevented them from understanding 
 
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clients? self-perceptions and behaviors when these cultural references were used to 
describe clients? experience. Similar to what has been discussed in domain 4, this result 
suggested that multicultural knowledge or a lack of cultural knowledge did sometimes 
affect a therapist?s clinical work, at least from the therapist?s perspective.  
East Asian counseling trainees in the present study variantly reported experiencing 
distrust from their challenging clients because of their international status. Some clients 
openly questioned participants? ability to understand and help them, which led to 
participants feeling uncomfortable. This result makes sense given the findings of research 
on in-group, out-group distinctions mentioned above. As noted earlier, individuals 
respond more favorably (e.g., show higher levels of trust and acceptance) to in-group 
members and endorse more biases toward out-group members (Hornsey, Oppes, & 
Svensson, 2002; Yuki, Maddux, Brewer, and Takemura, 2005).  
Attempts to address negative impact of culture. The first strategy participants 
used was disclosing about their cultural background (e.g., their international status) in the 
hope of alleviating the negative impact of culture.  However, if they were perceived as 
out-group members as discussed above, these disclosures may not have been effective in 
building trust. Tropp, Stout, Boatswain, Wright, and Pettigrew (2006), in their 
examination of the relationship between trust/acceptance and references to group 
membership among Caucasian, Asian American, Latino, and African American 
participants, found that when out-group members referred to their own group 
membership during an interpersonal interaction, people with whom they interacted 
experienced lower level of trust and acceptance of them. Within the context of the present 
study, East-Asian international trainees? self-disclosure of their international status in 
 
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session might have highlighted their out-group status, which may have made it harder for 
their clients to trust and accept them.  
Trainees in the current study also attempted to cope by emphasizing human 
experiences that were common and universal across cultures. This strategy may be 
effective given that Gaertner and Dovidio (2000), in their common in-group identity 
model (CIIM), suggested that bias toward out-group members can be reduced by 
recategorizing out-group members and in-group members into a superordinate group 
(e.g., using human being as the superordinate group that include both American and non-
 Americans). 
The lack of cultural discussion. About half of participants, however, did not 
disclose their cultural backgrounds to their clients or discuss cultural issues with them. 
These participants attributed the lack of cultural discussion to the fact that culture issues 
were not relevant in the challenging case. In addition, participants often did not have the 
chance to bring up cultural discussions due to pre-mature termination or weak therapeutic 
alliance.  
East Asian International Trainees? Training Experience in the US 
Helpful components of clinical training. East-Asian international trainees in the 
current study variantly endorsed training in counseling/psychotherapy theories and skills 
as helpful. Participant felt that exposure to a variety of counseling theories through 
reading and other training opportunities helped them feel more confident about their 
understanding of counseling. This result is not surprising given that international 
counseling trainees in previous studies identified learning about counseling theories and 
 
 92 
 
skills as one of the reasons why they went abroad to pursue a graduate degree  in 
counseling (Pattison, 2003) 
Participants in the current study also variantly reported opportunities to provide 
counseling to clients as a helpful component of their training in the US. Providing 
counseling increased participants? self-confidence, improved their clinical skills, and 
helped them examine their blind spots. This result is consistent with findings in the 
literature that direct contact with clients is facilitative of the development of a therapist. 
For example, Hill et al. (2007), with a sample of predominantly white counseling 
trainees, found that trainees had less performance anxiety and increased confidence after 
a semester of training. In addition, a number of studies (Jennings et al. 2008, Jennings & 
Skovholt, 1999; Orlinsky & Ronnestad, 2005) demonstrated that direct contact with 
clients facilitated the development of expertise of therapists from the United States, 
Europe, and Asia.  
Not surprisingly, supervision was another helpful component endorsed by East 
Asian international trainees. Participant noted that supervision played a critical role in 
helping them understand the relationship dynamics and built self-confidence as 
clinicians. This result is consistent with findings in the therapist development literature. 
For example, in Orlinsky and Ronnestad?s (2005) survey of 500 therapists with various 
levels of experience, they found that receiving supervision and/or peer consultation 
helped these therapists to develop their expertise.  
In addition, multicultural training and opportunities to work with culturally diverse 
clients helped the trainees in the current study enhance their cultural sensitivity. 
Participant indicated that being exposed to a variety of clients helped them understand the 
 
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multiple dimensions of diversity and view multicultural issues in their home countries in 
a different light. This result suggests that experiential learning (e.g., cultural immersion 
and/or exposure to cultural differences) may facilitate trainees to develop cultural 
sensitivity.  The facilitative effect of experiential learning on cultural sensitivity has been 
documented by McDowell, Goessling, and Melendez (2012) in their examination of 
marriage and family therapy master students? experience of participating in an 
international course that involved spending time in a foreign country. Participants in their 
study reported that immersion in a foreign culture provided them with opportunities to 
learn from cultural differences and subsequently increased their cultural sensitivity.  
Encouragement and support from academic programs and practicum sites were also 
suggested as a helpful aspect of training in the present study. Participant found it helpful 
when faculty/trainers in their programs were understanding of their experience as 
international students and invited them to talk about difficulties they experienced as a 
result of cultural differences. This result is consistent with Chen?s (004) findings that a 
positive learning environment in which trainees experienced a constructive relationship 
with fellow trainees, professors, and/or supervisors facilitated non-western counseling 
trainees? adjustment/learning. 
Areas in need of improvement in clinical training. Although there were many 
helpful aspects of training in the US, there were also some negative aspects. East Asian 
international trainees generally reported a lack of cultural sensitivity either in supervision 
or in their academic programs. Participants wished that professors were more aware of 
the needs of international trainees, so that international trainees would not have to 
struggle alone and advocate for themselves. This result is not surprising given Ng?s 
 
 94 
 
(2006) results from a survey of 36 counseling educators about their perceptions of 
international counseling trainees. Even though counseling educators agreed that 
international trainees should be treated as a separate group that is qualitatively different 
from American trainees, they did not seem to understand the unique needs of 
international students and paid little attention to helping international trainees succeed in 
their clinical placements.  
In addition, East Asian international trainees in the current study typically indicated 
that there was not enough multicultural training in their programs. Participant would have 
liked to have more training related to their culture of origin. This result is consistent with 
findings of Ng (2006b) that only 11% of counseling educators encouraged international 
students in their programs to choose class assignments or projects relevant to 
international students? cultures.  
Lastly, East Asian international trainees variantly reported wanting to have more 
opportunities to work with diverse clients, including clients from their own cultures. This 
result was is surprising given that all participants studied in counseling psychology 
doctoral programs located in the Mid-west area, and may not have much opportunity to 
work with diverse clients due to a lack of cultural diversity among the general population 
in that area. 
Limitations 
As is common to all qualitative research (Polkinghorne, 2005), the self-report, 
retrospective nature of the data may have had an impact on the findings. Participants 
were asked to recall and describe two clinical cases. Some of them chose to discuss cases 
that they had two or three years ago, and thus the accuracy of their recollections may be 
 
 95 
 
questionable. In addition, these cases were described from participants? perspective and 
the therapy process and outcome may have been different from the clients? perspective.   
Participants may also have been motivated to respond to questions in a socially 
desirable manner. For instance, coping strategies endorsed in the present study generally 
fell in the category of healthy coping. It is possible that some participants engaged in 
unhealthy coping but chose not to report it to maintain a positive image, especially given 
that they were East Asians talking with an East Asian interviewer.  
Third, the small sample size somewhat limits the generalizability of the findings, 
athough the relatively homogenous sample (i.e., female East-Asian international 
participants studying in counseling psychology doctoral programs located in the Midwest 
area of the US) makes it clearer to whom the findings should generalize. For example, 
one weakness mentioned about the clinical training was the lack of opportunities to work 
with diverse clients. This finding may be partially due to the limited diversity of the 
population in the Midwest US area, and may not be generalizable to East-Asian 
international trainees who study in an area with a more diverse population. In addition, 
the findings of this study are based on experiences of East-Asian international trainees 
and may not be generalizable to international counseling trainees from other cultural 
backgrounds. Furthermore, participants of this study are all beginning therapists. As a 
result, the findings of this study may not be generalizable to experienced East-Asian 
therapists. 
Finally, although steps were taken to minimize judges? bias (e.g., writing about 
and discussing expectations and biases at the beginning of the coding process and 
checking in throughout the coping process), judges? expectations and biases undoubtedly 
 
 96 
 
influenced findings. For instance, all judges expected that participants would encounter 
language barriers, which may have led us to interpret participants? responses as related to 
language barriers when these responses were ambiguous. Hence, results must be 
considered within the context of the particular research team of judges. However, the 
diverse cultural backgrounds of the research team (i.e., two East-Asian international, one 
Asian American, one African American, one Hispanic, and two Caucasian Americans) 
ensured that data were examined from multiple angles and individual judge?s 
expectations and biases were checked and balanced out to some extent.  
Implications and Future Directions 
Implications. Despite the fact that the number of international trainees enrolled in 
American counseling psychology doctoral program is fast growing, little attention has 
been paid to how to provide culturally sensitive clinical training to this population. Ng 
(2006b) surveyed 36 counseling educators who worked with international trainees and 
found that these educators did not seem to understand the unique needs of international 
students and paid little attention to helping international trainees succeed in their clinical 
placements. From the trainees? perspective, culturally sensitive training is much needed 
(Lee, 2013). Similarly, East-Asian international trainees in the current study experienced 
a lack of cultural sensitivity in their clinical training and wished to have more culturally 
sensitive training. The findings of the current study offered some insight into what may 
constitute culturally sensitive clinical training for East-Asian international trainees.  
First, counseling educators need to examine how they approach international 
trainees and perhaps shift their approach to a more culturally sensitive and strength-based 
approach. Park-Saltzman, Wada, and Mogami (2012) discussed two different approaches 
 
 97 
 
(i.e., the cultural-deficit approach and the culture-proficiency approach) from which 
counseling educators may understand and examine international trainees? experience. The 
cultural-deficit approach emphasizes international trainees? weakness (e.g., language 
barriers, a lack of understanding of American cultural nuances, discomfort working with 
emotions). Counseling educators who embrace the cultural-deficit approach often 
perceive international trainees? culture-related struggles as deficits and subsequently view 
international trainees as inferior to American trainees. In contrast, the cultural-proficiency 
approach emphasizes the unique strengths that international trainees bring to their clinical 
work (e.g., bilingualism and bicultural perspectives). International trainees? struggles are 
conceptualized as a result of mismatch between international trainees? preexisting 
knowledge/skills and the knowledge/skills required in the American culture.   
In my opinion, the cultural proficiency approach is a more culturally sensitive 
approach than the cultural deficit approach for two reasons. First, the cultural proficiency 
approach helps counseling educators recognize both strengths and weakness of 
international trainees, and subsequently allows counseling educators to form a more 
balanced evaluation of international trainees? abilities and performance. Second, the 
cultural proficiency approach encourages counseling educators to understand 
international trainees? weakness/struggles within the context of their cultures of origin. 
Second, culturally sensitive training involves counseling educators recognizing 
East-Asian international trainees? culture-related strengths and helping them to build on 
these strengths. As noted earlier, the findings of this study suggest that East-Asian 
international trainees? cultural backgrounds can be facilitative to their clinical work. It 
would be empowering for East-Asian international trainees if counseling educators help 
 
 98 
 
them to reflect on the facilitating effects of their cultural backgrounds and discuss with 
them how to use these backgrounds in a therapeutic way. In addition, although East-
 Asian international face a number of challenges, they have developed coping strategies 
and are resilient and resourceful. Discussion with East-Asian international trainees about 
their coping strategies and adaptive personal attributes can be empowering as well.  
Third, culturally sensitive training requires counseling educators to understand 
East-Asian international trainees? struggles within the context of their cultural 
backgrounds, and to make culturally sensitive evaluations of East-Asian international 
trainees? performance.  For example, the findings of this study suggest that some of East-
 Asian international trainees? struggles, such as discomfort working with emotions and 
struggle with being direct with clients, are a result of East-Asian cultural values and 
practices. It would be helpful if counseling educators recognize the impact of East-Asian 
cultures on international trainees? struggles in these areas and correctly attribute their 
struggles to cultural factors rather than skill deficiency. 
Lastly, culturally sensitive training involves helping East-Asian international 
trainees develop skills required to cope with clinical challenges. For instance, given that 
trainees generally encounter distrust or discrimination from their clients, it would be 
helpful for the instructors of practicum classes to initiate discussion about how to deal 
with discrimination in session and role-play with trainees about how to cope with 
discrimination/distrust.  
In addition to culturally sensitive clinical training, East Asian international 
counseling trainees may benefit from curriculum that includes coursework, academic 
assignments, or readings that are culturally relevant to them. The incorporation of 
 
 99 
 
readings from other countries or cultures into curriculum would not only meet 
international counseling trainees? needs, but could also help American counseling 
trainees enhance their multicultural awareness and competence (Leong and Ponterotto , 
2003; Heppner, 2006). 
Even though this study was not designed to understand East-Asian international 
trainees? experience with supervision, several important issues related to supervision 
emerged from the data. East-Asian international trainees generally reported that they 
sought support and feedback from their supervisors when they encountered challenges, 
which suggested that clinical supervisors served as a main support for this population. 
However, trainees typically reported experiencing a lack of cultural sensitivity and even 
discrimination in supervision. It is likely that East-Asian international trainees who 
attempt to seek support from their clinical supervisors receive support from some 
supervisors and do not get support from other supervisors due to the lack of cultural 
sensitivity in supervision. These findings highlighted the importance of culturally-
 sensitive supervision. 
Participants? recounting of the frustrating aspects of their supervision offered 
some insight into what trainees may be looking for from a culturally sensitive supervisor. 
For instance, one participant said ?I usually bring up discussion of my cultural identity in 
supervision, and I don?t think a lot of times it draw attention of the supervisor,? which 
suggests that one element of culturally sensitive supervision is talking about cultural 
issues.  This suggestion is consistent with the finding of existing supervision literature 
that discussion of cultural issues in supervision is positively associated with international 
clinical trainees? satisfaction with supervision (Mori, Inman, & Caskie, 2009). Another 
 
 100 
 
possible element of culturally sensitive supervision involves supervisors understanding 
East-Asian international trainees? unique experience of conducting therapy in the US and 
helping East-Asian international trainees to better cope with challenges as well as to 
make the best use of their strengths.  
The findings of the current study also shed light on strategies that East-Asian 
international trainees may employ to help them succeed in their clinical placements. For 
instance, it is important for East-Asian international trainees to recognize both strengths 
and challenges that associate with their international status. It would also be helpful for 
international trainees to help their clients understand that their experience as an 
international trainee (e.g., bicultural experience) may facilitate the therapy and/or to 
discuss with their clients about some of the challenges associated with being an 
international (e.g., accent) in an honest but non-apologetic way.  
Future research. It would be interesting to follow up on the findings about self-
 disclosure related to trainees? international status. As noted earlier, according to social 
identity theory and self-categorization theory (Tropp, Stout, Boatswain, Wright, & 
Pettigrew, 2006), the effect of self-disclosure may vary depending on whether a client 
perceives an international trainee as an in-group or out-group member. When an 
international trainee discloses to clients about his/her international status, the self-
 disclosure might exacerbate the in-group or out-group designation. Specifically, when 
clients perceive the international trainee as an in-group member because of their similar 
cultural backgrounds or experience, the international trainee?s self-disclosure is likely to 
make the client respond more favorably in counseling (e.g., the client may have increased 
trust in the international trainee). In contrast, if a client perceives an international trainee 
 
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as an out-group member, the international trainee?s self-disclosure of his/her international 
status is likely to elicit more out-group bias from the client and subsequently hinder the 
therapeutic relationship. It would be interesting to conduct a study to further examine 
how clients respond to East-Asian international trainees? self-disclosure of their 
international status and determine whether clients? responses are moderated by clients 
perceiving international trainees as in-group or out-group members.  
A final implication for research relates to the findings about supervision. The 
present study highlighted the importance of culturally-sensitive supervision, but it was 
not clear what constitutes culturally sensitive supervision. Research on supervision 
involving international supervisees is very limited and existing literature mostly focused 
on examining how international supervisees? characteristics (e.g., training level, 
acculturation level, course self-efficacy) related to critical events (e.g., discussion of 
cultural issues in supervision) or satisfaction with supervision (Mori, Inman, & Caskie, 
2009; Nilsson, 2007; Nilsson & Anderson, 2004; Ng & Smith, 2012). It would be 
worthwhile to conduct a qualitative or survey study to investigate the elements of 
culturally-sensitive supervision. 
  
 
 102 
 
Appendix A 
Recruitment Emails 
Snowball Sampling Email 
Subject: Dissertation Recruitment Help! 
Dear ___________, 
 
I am writing to ask a huge favor of you regarding recruiting participants for my 
dissertation. You can help me immensely in two different ways: with your own 
participation in my study and/or by referring me (sending me names and email addresses) 
of individuals whom you think would be eligible and interested in participating in this 
study. 
What is my study about? My dissertation study is a qualitative investigation of East-
 Asian international trainees? experiences of conducting therapy/counseling in the U.S. In 
order to investigate this topic, I will be conducting two, 1 to 1.5 hr telephone interviews, 
arranged at times of mutual convenience, approximately one week apart. I will use the 
attached protocol as well as probe about things that come up in the interview; I will also 
be taping the interviews and transcribing them for analysis, and we will treat the data 
according to ethical guidelines. In anything written, all identities will be concealed to 
maintain confidentiality. If you decide to take part in this study, you have the right to 
refuse to answer any question(s) during the interview and/or withdraw from participation 
at any time. 
Who is eligible for my study? I am looking for participants who are East-Asian 
international students in doctoral programs in counseling/ clinical psychology. In 
addition, eligible participants need to have at least two years of supervised clinical 
experience working with adult clients in the U.S. I define East-Asian international 
trainees as trainees originally from China, Hong Kong, Korea, Japan, or Taiwan. 
If you feel comfortable participating in this study (despite the fact that we know 
each other), I would love have you participate. Unfortunately, I cannot offer any 
monetary compensation, but I hope that the interviews will provide you with a good 
opportunity to reflect on yourself as a therapist/counselor, and your experience of doing 
counseling/therapy in the U. S as an international trainee. There is a slight risk to 
participating in that sharing your experience as a trainee may be uncomfortable, but I 
assure you that my purpose is to understand and not to judge. If you do not feel 
comfortable or are unable to participate, I will understand.  
If you decide to take part in the study, you have the right to withdraw from 
participation at any time. If you have questions about your rights as a research subject or 
wish to report a research-related injury, please contact : Institutional Review Board 
Office, University of Maryland, College Park, Maryland, 10742; (email) irb@deans, 
umd.edu; (telephone) 301-405-0678. 
Regardless of whether or not you personally choose to participate, I am hoping that 
you can help out with recruitment by providing me with the names and email addresses 
of your fellow East-Asian trainees who might be interested in participating. Although I 
would also greatly appreciated it if you could encourage them to participate, please do 
 
 103 
 
not simply forward my email to them yourself, as I would like to contact all potential 
participants directly in order to be able to calculate a return rate. 
 
Thank you very much for your help! If you have any questions or concerns, please 
feel free to contact me. I can be reached at jliu@psyc.umd.edu or (301)461-6724. I look 
forward to hearing from you. 
 
Sincerely,  
Jingqing Liu 
 
Initial Recruitment Email 
 
Subject: Study on East-Asian international trainees? experience of doing therapy in 
the US 
Dear _____________, 
 
Have you ever wondered how much you learned in the US can be applied to your 
home country? How have your East-Asian culture background played out in your work 
with your clients in the U.S? What kind of challenges you have experienced when 
working with clients in the US? How have you coped with these challenges? Would you 
be willing to tell me your thoughts about these questions? 
 
My name is Jingqing Liu, and I am a 4th-year doctoral student in the counseling 
psychology program at the University of Maryland-College Park. Dr. Clara Hill is my 
academic advisor. I cordinally invite you to participate in a qualitative study on East-
 Asian international trainees? experiences of doing therapy in the US. This is my 
dissertation project, and I would be extremely grateful if you would consider 
participating. You can find more information about this study through the following link: 
 
http://www.surveymonkey.com/s/7FFRG8L 
 
Please reply back and let me know whether or not you are interested in participating. 
 
Sincerely, 
Jingqing Liu, M.A., M.S             Clara E. Hill, Ph.D. 
Doctoral Candidate                     Professor 
301-461-6724                        301-405-5791 
jliu@psyc.umd.edu                 hill@psyc.umd.edu 
 
 
Follow-Up Recruitment Email: No Reply 
 
Subject: Participation in International Trainees Experiences of Doing Therapy in the 
US 
 
Dear __________________, 
 
 104 
 
 
Approximately one week ago, I contacted you about participating in my doctoral 
dissertation, a qualitative study on East-Asian international trainees? experiences of doing 
therapy/counseling in the U.S. As I have not yet heard back from you about your interest 
in participating, I would like to again invite you to participate.  
Recall that the study would involve two, 1 to 1.5 hr telephone interviews arranged at 
times of mutual convenience, approximately one week apart. I will use the attached 
protocols as well as probe about things that come up in the interviews; I will also be 
taping the interviews and transcribing them for analysis. Your name and any other 
identifying information will be removed from the transcript, and we will treat the data 
according to ethical guidelines. Only members of the research team will have access to 
the interview tapes, which will be stored in a locked, secure location and will be 
destroyed upon completion of the study. In anything written, all identities will be 
concealed and camouflaged as needed to maintain confidentiality. If you decide to take 
part in the study, you have the right to refuse to answer any question(s) asked of you 
and/or withdraw from participation at any time. I hope that the interviews will provide 
you with a good opportunity to reflect on yourself as a therapist/counselor and your 
experience of doing therapy/counseling in the U.S. There is a slight risk to participating 
in that reflecting on your struggles as an international trainee could be uncomfortable, but 
I assure you that as an international trainee myself, I?ve been through some struggles, and 
my purpose is to understand and not to judge. Note that scheduling the interview will 
imply informed consent on your part. 
Please write me back at your earliest convenience in order to let me know whether 
or not you are interested in participating. 
Thank you very much for your consideration! If you have any questions or concerns, 
I can be reached at jliu@psyc.umd.edu or (301) 461-6724. I look forward to hearing from 
you. 
Sincerely,  
Jingqing Liu 
 
 105 
 
Appendix B 
Demographics Questionnaire 
 
Please complete this questionnaire and return it to me via email 
(jliu@psyc.umd.edu) prior to our scheduled interview. 
 
Gender (Circle one):  Female  Male       Age:_________ 
Country of Origin:________ 
Type of Graduate Program (circle one): Master   Psy. D     Ph.D 
Specialty area (Circle one):  clinical / counseling 
The number of years living in the US:__________ 
The number of years seeing clients in the US: _________ 
Settings in which you have seen clients (indicate approximate # of hrs in all that 
apply): 
     University Counseling Center (# of hrs_____________) 
     University Mental Health Center (# of hrs___________) 
     Community mental health center (# of hrs ___________) 
     Psychiatric hospitals (# of hrs______________________) 
     Other: ________________(# of hrs_________________) 
Please note how much you believe in and adhere to the techniques of the following 
theoretical orientations, where 1 = not at all and 5 = completely: 
Humanistic/Experiential/Existential _________ 
Psychodynamic/Psychoanalytic/Interpersonal _________ 
Behavioral/Cognitive-Behavioral _________ 
Feminist/Multicultural_________ 
System/family_________ 
Please rate your agreement to the following statement where 1 = strongly disagree, 5 
= strongly agree:  
I intend to see clients as part of my future career ________ 
I plan to go back to my home country to practice counseling________ 
Have you received training on counseling/therapy in your home country?  Yes / NO 
   If yes, please describe what kind of training is it: 
 
 106 
 
Appendix C 
Interview Protocol 
 
Introduction: Thank you for agreeing to participate in my qualitative study 
examining 
East-Asian international trainees experiences of doing therapy in the U.S. Just a reminder 
that I am taping this interview, the interview will be transcribed for the data analysis, and 
your name any other identifying information will be removed from transcripts. Only 
members of the research team will have access to the tapes of this interview, which will 
be stored in a locked, secure location and will be destroyed upon completion of the study. 
Your participation in this study is completely voluntary; as you have the right to refuse to 
answer any question(s) asked of you and/or withdraw from this study completely at any 
time. I will maintain strict guidelines related to the safeguarding of research material as 
defined by the American Psychological Association. Do you have any questions? 
 
I am going to ask you a number of questions about your experience of doing 
therapy/counseling in the U. S. Because social desirability can be of concern in an 
interview study such as this one, I want to assure you that my purpose is to understand 
and not to judge. Please say whatever comes to your mind in response to the questions. 
Please note in this interview, I use therapy and counseling interchangeably. 
 
1. How would you describe your cultural background? 
Probes:  
a) Inquire definition of the specific culture with which the interviewee identifies 
him/herself 
b) Ask personal experiences related to culture 
c) How much do you adhere to your culture? 
2. Could you tell me about your approach to therapy?  
3. How does your approach to therapy fit your cultural and personal background? 
4. How would you feel about trying to use this approach in your home country? 
5. If you go back to your home country to practice therapy, what aspects of your clinical 
training in the US would be most helpful?  
Probes:  
a) What would you like to add in your clinical training to make it more relevant to 
your home country? 
6. What are challenges that you experience as an international trainee in terms of 
working w/ clients in the US? 
 
 107 
 
Probes: 
a) Have you experienced language barrier in your work with clients in the US? 
b) Have you experienced any cultural conflicts (or difficulty) in your work with 
clients in the US that is related to your cultural background? And how the 
difficulty was handled?  
c) Have you experienced any discrimination in your work with clients in the US that 
is related to you being an international trainee? Ask details about the case in 
which interviewees experience discrimination (i.e. how did the case go? How the 
discrimination was handled? How were you feeling about the way in which the 
discrimination was handled?) 
7. How do you deal with these challenges?  
Probes: 
a) What kind of support you got that help you to better cope with these challenges? 
b)  What personal (or internal) factors (i.e. personality, attitudes, values, past 
experiences, etc) help you to better cope with these challenges? 
8. Tell me about one case in which your cultural backgrounds facilitated your work w/ 
your client? 
Probes: 
a) Tell me more about your relationship with this client? 
b) How did your cultural background affect your work with this client? 
c) Did you talk about cultural issues in this case? How did you feel about discussing 
cultural issues with this client? How do you think the discussion of cultural 
issues impact your work with this client? 
d) Are there your personal reactions that influence your ability to deliver therapy? 
what I am asking is countertransference. 
e)  How do you feel about self-disclosing to this client? 
f) How do you feel about using immediacy w/ this client? Immediacy is defined as 
discussing your relationship with clients in here-and-now. 
g) Are there any negative aspects of this case? 
h) What support did you receive for dealing with cultural issues in this case? 
9. Tell me about a different case in which your cultural backgrounds hindered your work 
 
 108 
 
w/ your client? 
a) Tell me more about your relationship with this client? 
b) How did your cultural background affect your work with this client? 
c) Did you discuss culture in this case? how the process of discussing culture is 
like? How did you feel about discussing cultural issues with your client? How do 
you think the discussion of cultural issues impact your work with this client? 
d) Tell me about some of your personal reactions that influence your ability to 
deliver therapy? What I am asking is countertransference. 
e)  How do you feel about self-disclosing to this client? 
f) How do you feel about using immediacy w/ this client? Immediacy is defined as 
discussing your relationship with clients in here-and-now. 
g) What support did you get for dealing with cultural issues in this case? 
10. In terms of doing therapy in the US, what?s the wisdom that you want to give fellow 
international students before they come to the US? 
 
 
 
 109 
 
Appendix D 
Collectivism subscale of the Asian American Values Scale ?Multidimensional 
Please circle how much you agree/disagree with the following statements based on 
your personal values. 
 
1. The welfare of the group should be put before that of the individual. 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
2. One?s efforts should be directed toward maintaining the well-being of the group 
first and the individual second. 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
               1       2       3      4        5       6       7 
3. One?s personal needs should be second to the needs of the group 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
4. The needs of the community should supercede those of the individual 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
5. One need not always consider the needs of the group first * 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
6. The group should be less important than the individual * 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
7. One need not sacrifice oneself for the benefit of the group * 
Strongly disagree            neither agree              strongly agree 
                            nor disagree 
        1       2       3      4        5       6       7 
Note: * indicates reversely scored items. 
 
 
 
 
 110 
 
Appendix E 
Table 1. List of Domains, Categories, Sub-Categories, Frequencies, and Illustrative 
Quotations for All Data 
Domain, categories & Sub-
 categories 
Frequency Illustrative quotation 
Culture-related challenges 
in conducting therapy in 
the US 
 
  
A. Perceived distrust 
or discrimination 
from clients 
General 
(10) 
 
 
1.  Clients reject 
participants? 
service 
Typical (6) ?One of my clients, when I was in my very 
beginning doing the practicum in my 
Master?s program, and my client just said 
very rude, about me. And, she said  ?because 
you have accent and I don?t like a counselor 
with accent. So, can I change counselor??.. I 
feel very shocked about that. Even though we 
can communicate well. And my supervisor 
just watch  my  sessions with this client, and 
my supervisor just advocate for me and just 
say ?she can understand your English, so that 
shouldn?t be problem?. So, so, even though in 
the end, we just assign her another counselor, 
but I feel very hurt in that experience? (case 
PT) 
2. Participants 
experience 
covert 
discrimination 
from their 
clients 
Variant (5) ?I would say more covert [discrimination]. 
Sometimes clients see me as a Chinese 
woman and they would.. I even have a 65 
year old female client who said something 
like ?oh, the Chinese woman are blah blah 
blah? I felt like that was directed at me 
because I am a Chinese woman. Or 
sometimes they will refer to someone else 
actually Like ?oh that Chinese the other day 
did some [bad] stuff?.. I felt like that was 
some kind of discrimination. That?s not 
directly targeted at me, but I feel like that?s 
relevant. Those are more, not like overtly 
saying you?re Chinese, blah blah, but 
indirectly making some comments that are 
very stereotypical or negative about 
 
 111 
 
Chinese.? (case YH) 
 
?I led an international student support group 
last year, and what I?ve noticed is that [group 
members] were more interested in having 
Caucasian counselors. they weren?t really 
listening to the training I was giving or what 
I was suggesting sometimes because my 
background is an international  in America? 
it was kind of ironic, because, I thought I 
would get that kind of feeling when I?m 
working with American students, not 
international students, but it was totally the 
opposite.? (case MS) 
3 Clients 
question 
participants? 
abilities to help 
them 
Variant (4) ?Sometimes when the client is very aware of, 
of the cultural differences, and they question 
my ability to understand them, I try my best 
but sometimes I feel like it?s, it?s really 
difficult to work with those kinds of clients. I 
mean they?re continuously questioning 
whether I can understand them, whether I can 
shed some light on their problems or, so I 
thought that was a challenge? (case MS) 
B. Language Barrier General (9)  
 
1. Participants 
have difficulty 
understanding 
their clients 
Variant (4) ?I think the first thing is the language barrier. 
Even though I sometimes sound like a native, 
like an American, like I grew up here all my 
life. That?s not true. So, there are times when 
I don?t understand what the client says and I 
know that.? (case MS) 
 
?There are times when the internal conflicts 
that the clients may say something that I 
didn?t get it, but they were speaking so fast 
that I have to say ?do I want to ask the client 
to clarify that for me, or should I let it go?? 
so you have to make a decision in your mind 
about how to address that piece of missing 
information. That kind of relate to ?if I ask, 
will I look incompetent to the client or that 
would actually be helpful??........ . If you have 
a client who keep saying ?huh? What do you 
say?? ? and then they don?t come back. You 
wonder if it?s because of you they don?t want 
 
 112 
 
to come back.  ?The client may just drop 
out anybody. But I think that being 
international makes that sometimes you take 
things more personal especially when it 
relates to, questions, your language ability.? 
(case YH) 
2. Clients 
respond 
negatively to 
Participants? 
accent 
Variant (4) ?The biggest one would be language barrier, 
and accent is the obvious one, and sometimes 
clients question my ability to help them or 
question about my authority because English 
is not my first language and I do have an 
accent and some people worry if I can 
understand what they are saying, and then?. 
or there are other people who just simply 
don?t trust anybody with accents, so that?s, 
that?s been a challenge for me? (case RK) 
3. Being a non-
 native speaker 
negatively 
affects 
participants? 
self-confidence  
Variant (3) ?Only thing I feel much challenging here is 
the like, language. I mean in Korea I feel 
more confident to convey what I?m thinking 
or sharing my feedback to clients. But here I 
feel less, much less confident of doing that. 
So, so I mean, I, so I, here, I mean what, 
what is the difference between working in 
Korea and working here, I mean, I try to 
listen more here than in Korea.? (case JJ) 
4. Participants 
feel restricted 
in their 
abilities to 
express 
themselves in 
English 
Variant (2) ?We know that it?s very important to ask 
about client?s feelings. ?how do you feel? 
right? But I feel like, not growing up in this 
country, my way of expressing certain things 
are more limited. Like I know how to ask 
how do you feel, but maybe for an American 
they might have multiple ways to get at the 
same thing. They might say ?what?s that like 
for you to feel that way? or ?when that 
happens, what was going on? but then for me, 
these are all the things I have to learn. Like 
just like I was learning English. This doesn?t 
come natural for me. So that?s what I?m 
saying language is not just about whether I 
pronounce correctly, but also the 
expression.? (case YH) 
 
C. A lack of 
understanding of 
nuances of 
American culture 
Variant (5) ?One big thing would be, sometimes the lack 
of reference, lack of knowledge of my 
client?s cultural background. And that make 
me less sensitive and less knowledge as a 
 
 113 
 
(e.g., cultural 
reference, social 
norms/cues, values 
and practice of a 
particular culture, 
etc.) 
counselor. For example, this year I work at a 
shelter with residential clients and outpatient 
clients who are survivors of domestic 
violence and sexual assault. At the first 
semester of my pracitcum there, I found a lot 
of difficulties working with my African 
American clients, African American female 
clients, because of my lack of knowledge of 
their cultural background, their cultural 
values and norms and the lack of reference of 
their interpersonal styles?. So I found 
myself spending a lot of time, little by little, 
learning those from my clients. And of 
course that hinder my capacity as a counselor 
to help them? (case HC) 
 
?I?m not familiar with some American 
cultures like, their high school life, or like 
their, their childhood or like some like, like 
for example like, some TV show or some 
movies.I don?t know well about like 
American TV show or like American movies 
or American.? (case JJ) 
 
?Another thing is culture difference. 
Especially oppression and discrimination, 
stuff like that. Personally I don?t have the 
experience with how people?s racial identity 
affects their relationship. So I feel like I was 
stuck in between. Like I identify with some 
white culture but the people of color see me 
as immigrant and they expect me to be on 
their side. ? I don?t have personal 
experience like living in the state?I am not 
aware of very subtle issues [related to 
oppression and discrimination]. Say, some 
people of color, they might interpret the 
behavior of whites in a different way. But I 
didn?t see that way so I?m blind to that, to 
that perspective.? (case WX) 
D. Countertransferen
 ce due to cultural 
conflicts 
Variant (4) ?Maybe in East-Asian countries we value the 
feeling of parents, we need to respect our, 
parents and, elder family members. But in 
the United States, they don?t even have those 
concepts in their mind. So sometimes when, 
when I hear their behavior is very rude to 
 
 114 
 
their parents, or they just take their parents 
effort for granted, I, I just feel very angry 
about that. So, that, that?s the cultural thing, 
so, that could make me feel very angry?. 
sometimes I just struggle whether I should 
stand on parent?s side or on my client?s side? 
(case PT) 
E. Discomfort 
working with 
clients? emotions 
Variant (3) ?One of the first challenges was for me to 
focus on emotions. ?In Korea, or in most 
Asian countries, what I understand is that, we 
don?t usually focus on emotions. We talk 
about our minds, our behaviors, and how to 
fix the problem, and how to work it out. 
Those kind of things . So, it was really hard 
for me to focus on the emotions because it 
was really uncomfortable. I felt like, if I go in 
there, the client might not like it, even though 
it?s our job.? (case MS) 
F. Inability to meet 
clients? expecations 
Variant (3) ?I can give you an example yea. I don?t 
remember when? One Asian client was 
from Canada, was an immigrant to the states. 
And during the session, he always expect me 
to understand where he came from and how 
he thinks and the way he interpret things. 
Like, there were a lot of assumptions, like 
?You are Chinese and you are Asian so you 
should understand what I mean?. And I am 
very uncomfortable about it. I feel like we 
should be more open and articulate and 
expressive of what?s really going on in your 
mind.? (case WX) 
G. Difficulty being 
direct with clients 
Variant (3) ?I am trying to challenge my client, but what 
I do is I paraphrase his sentence, by 
emphasizing on some word and hoping he 
can identify this word, and you know. I 
thought I was challenging him, but he?s 
American people, he didn?t recognize it as a 
challenge, but as a reflection? (case LT) 
Coping with culture-
 related challenges 
  
A. Coping Strategies    
1. Seeking support & 
feedback 
General 
(10) 
 
a. From supervisor General (9) ?I, I try to, like, get support, seek support 
from supervisor and colleagues?. I had two 
supervisors last year, and they are also 
 
 115 
 
international trainees. So they, yeah, they, 
they know, like those issues very well, so 
they tried to like normalize it, and they share 
their own experience. And, so they, yeah, 
they tried to like normalize it and give me, 
much support. And my, and my like other 
supervisors who is like from here, who are 
from here, they always try to, they are always 
like, try to listen my perspective as an 
international trainee. So, yeah and also they 
try to, like, yeah they try to value my own 
like perspective. So yeah they are very 
supportive? (case JJ) 
b. From 
colleague/peers/cla
 ssmates 
General 
(10) 
?Interestingly, for the working alliance part 
and for the look, the discrimination part, I 
actually never discuss with my supervisors. I 
always discuss with my international friends, 
international peers. I guess the reason why I 
never discuss with my supervisors, that I 
never trust them they would ever understand 
my experience. But I trust that all my 
international students can understand what I 
mean and can relate to me. So when I have 
those challenges, those discriminations, or 
the hard to establish working alliance with 
my clients, I always debrief with my 
international friends, my cohort and my 
partner. I feel like they can understand me 
better, they can support me, deal with these 
kind of challenges.? (case HC) 
c. From 
Advisor/other 
faculty member 
Variant (3) ?I?m currently getting my practicum in 
counseling center, and our practicum 
instructor, she is really amazing. She?s and 
experienced counselor, so I think she is really 
into feminist theory, so she really respect, 
respectful and try to, uh, she?s really respect. 
Respect other people?s feelings, thoughts and 
ideas. I feel pretty comfortable asking for 
help and we kind of discuss the language 
thing.? (case LT) 
2. Addressing 
cultural issues 
with clients 
General (9)  
a. Participants 
disclose to clients 
about participants? 
Typical (6) ?every time when I talk to my client, the first 
time, after we talk about confidentiality, I 
always told them that I am an international 
 
 116 
 
international status student, my language, English is my second 
language, so probably there are some 
language difficulties, if they felt like there 
are some difficulty understanding me just ask 
me to repeat or if I have some problem with 
understanding them I will ask them 
questions, so I guess now I felt pretty 
comfortable doing things like these, I do it 
with every client that I have, and then I felt 
they are more comfortable with it, and I am 
more comfortable with it, and it hasn?t been 
an issue, at least with the current clients I 
have? (case LT) 
 
?I think [whether I disclose my background 
as an international] depends. I think for me 
first I would gather the client?s 
comfortableness with me?. a lot of my 
clients are pretty comfortable so I don?t feel 
the need to always bring that up. To say ?I 
wanted to let you know, I?m speaking 
English with some accent, should any point 
that you don?t understand me, you have to let 
me know.? Or just like ?we come from very 
different cultural backgrounds, at times I may 
not understand you? I don?t do that... Some 
therapists may have that as their opening 
with any client. That?s not me. Have I tried? I 
did, but I don?t somehow, my experience 
didn?t see how much that impacted my work 
with my clients. It?s really kind of case by 
case situation? (case YH) 
b. Participants invite 
clients to voice 
discomfort they 
may have   
Variant (4) ?I would usually add something like, even 
though we were raised in different countries 
and different times but there must be 
something in common, so I hope if the way I 
approach you seems offended or not 
appropriate, please talk about it. Please talk 
to me about it. I would say that.? (case WX) 
c. Participants share 
with clients about 
their internal 
cultural conflicts 
Variant (3) ?[when experiencing internal cultural 
conflict, if I have really strong feelings about 
it I will be honest with my clients about like 
how this impact me, I would tell them that 
personally I really value education and be 
honest with them, and normally when I tell 
them how I feel, it actually feels better for 
 
 117 
 
me?I will also try to ensure them that I 
respect their decisions and will help them to 
make a decision for themselves, and I?m sure 
a lot of people in  their life already telling 
them what their should do and I would hope 
to not be that person? (case QZ) 
 
d. Participants offer 
clients the option of 
referring them to 
another counselor 
Variant (2) ?I tell them, well, we could try working out, 
and, if you feel like we?re not really 
connecting, and we?re having difficulties, 
please let me know, so that I could find 
another counselor that you might be happy to 
work with.? (case MS) 
e. Participants ask 
clients to 
explain/elaborate on 
words that 
participants did not 
understand 
Variant (2) ?Recently, [when I hear a word that I don?t 
understand] I feel more open about asking, 
?Oh, I hear this interesting term, and I?m not 
quite understand what you?re talking about. 
Can you explain it to me? Can you help me 
to understand it more?? ? At the beginning I 
feel like oh that?s my fault that?s my sin for 
not understanding this word. But right now, I 
feel more comfortable and I feel like asking 
my client explain a specific thing for me can 
actually be beneficial for them, because it 
gives them an opportunity to reflect on what 
they really mean. And even explore the 
cultural meaning behind a specific word or a 
specific phenomenon. It gives them a second 
chance to think it through to think more 
critically.? (case HC) 
f. Participants are 
more attentive to 
clients 
Variant (2) ?I still speak not so good English. But I guess 
the attitude, the comfortness, the working 
alliance, my expression, my facial 
expression, and my attitude that demonstrates 
my client, I care about them. And I am fully 
present in the counseling room with them for 
the hour.  I?m totally stay with them. I think 
that is the most important thing. And I guess 
because of that, I get a sense that my clients 
also want to work with me at that time.? 
(case HC) 
3. Improving English 
skills 
Typical (7) 
?in case of English, I found an undergraduate 
student here in our school, who does like, 
exchange languages. We meet together once 
a week and talk about, discuss about topics 
 
 118 
 
and talk about our lives. So, I could, keep, 
you know improving my English. And I try 
to read a lot of books. It might not 
necessarily help, but it definitely increases 
my vocabulary. When compared to just 
memorizing vocabularies. Reading makes it 
easier so I try to read books. You know, 
maybe learn different words, or, emotion 
words that I could use.? (case MS) 
?I think that I have really pushed myself to 
improve [English] was maybe the main way 
that I deal with it?. For the next two years I 
mainly live with Americans, families or 
roommates. Those times were extremely 
helpful. I would say it?s not about how I 
could say or how fluently I could speak 
English, but more self-efficacy. I think just 
the ease of being able to? I mean, I continue 
to make mistakes, and I think that I would 
never ever stop making mistakes about 
speaking English.  But it?s just more the 
comfort level. I think that comfort level 
helped with my therapy work to stand, I 
became less self conscious about what I was 
saying, so I could really get the energy, I 
have more engery that go to listening to my 
clients. I felt that I was more able to be 
present with my clients because I don?t 
struggle, I mean, I struggle less internally.? 
(case HC) 
4. Using cognitive 
restructuring 
Typical (6) ?this is kind of a reminder for me I should try 
not to blame my English skills too much, 
because I am a learning counselor, and I 
don?t have a perfect counseling skills, so 
maybe that was the reasons that clients don?t 
trust me or don?t come back so um, for that?s 
one part, if something is not going well I try 
not to blame my English skills too much. and 
the other part is I?m also doing um phone 
counseling, um, crisis hotline, and then there 
I have a lot of opportunity to observe other 
counselors, they are not professionally 
trained counselors, but they went through 
trainings, and most of them are native 
speakers, and even for them  sometimes I 
 
 119 
 
saw they were hung up.  so it happened to me 
I tend to think oh is it because of my accent 
or what, but knowing this happens to 
everybody kind of gives me a reminder that 
this happens all the time and sometimes the 
reason is not me? (case RK) 
5. Using avoidance Variant (5) ?my colleague is also Asian counselor, her 
client called and request a different counselor 
because of her accent, and that scares me too 
and makes me even more self conscious next 
time when I call a client. So for a long time I 
switched to email [clients] because clients 
are not going to know like they are going to 
get, they are still going to see my name and 
probably know I am a foreigner, but it just 
made me feel more comfortable 
communicating through email? (case QZ) 
6. Practicing self-
 care 
Variant (4) ?I?m very like, I really like self-care, so I try 
to like, to make the good relationship outside 
of like my work? (case JJ) 
 
?exercise, take care of myself, and have fun 
with my friends and talk about it talk with 
my family is very helpful for me, even 
though they don?t really totally understand 
and I won?t tell them what exactly happened, 
its soothing and comforting to talk to them? 
(case QZ) 
 
?I always have my therapists? I think 
having a place to talk about what happening 
in my life and to hear someone hear it and 
understand it has been really helpful. Not just 
about helping me managing my stress, but 
also helping me to examine myself at a level 
that other people may not be able to do, 
because then I could be completely 
vulnerable and honest without worrying 
about whether I?m meeting other people?s 
expectations? (case YH) 
B. Facilitative personal 
attributes  
  
1. Adventurous 
nature/openness to 
new opportunities 
or challenges 
Variant (5)  ?I think, I, personally I like challenges, 
because I think it gives me like a chance that 
I, can make development, and then I can be 
growing, so that?s why I like challenges. And 
 
 120 
 
also, I like, I like to learn, learn like, I like to 
have new experiences. So, whenever I have 
like some issues or problems I try to think 
that oh it will be a like good chance for me to 
learn something from that experience. So 
then, those kinds of attitudes, they?re helpful 
for me to cope with the issues? (case JJ) 
2. Perseverance Variant (4) ?I think perseverance is helpful for me. My 
father instilled in me that you don?t give up 
and no matter how hard it is, and  you start a 
goal and you know it?s what you want, you 
stick with it. A quote that I like is ?you do 
what you have to do to do what you want to 
do?, and that?s what keeps me motivated and 
keep me going? (case QZ) 
3. Optimism Variant (3) ?I guess one thing will be that, I try to stay 
positive. Even though at one of those worst 
moments that I, I cry, and those kinds of 
stuff, like, sometime later I joke about it. 
And it really becomes laughable because, I 
realize even though it was hard at that time, 
sometimes it?s just, kind of, ridiculous to see 
me, making a scene of something that isn?t 
really, really, what is it?a tragic thing. .I 
guess that, that could be one of my strengths? 
(case MS) 
4. Good 
interpersonal skills 
Variant (2) ?I mean at different settings I care about the 
people I work with and I took time and took 
the energy to work to get to know them. Not 
just remember their names passing by. I 
would sometimes get to know them as 
person, their personal life, their kids, their 
families. Sometimes I share stuff like food or 
offering help and all those I feel like, allow 
me to have some good relationship with 
people, I think that benefit, that helped when 
I encounter difficulties I go to them, I think 
they are very willing to help me out? (case 
YH) 
5. Spirituality Variant (2) ?Spirituality. I mean, I have religion, I 
believe in God. So, when I have problem, I 
pray, so that is helpful? (case JJ) 
The Impact of 
participant?s cultural 
backgrounds on therapy in 
the positive case 
  
 
 121 
 
A. Cultural 
background/experien
 ces facilitate therapy 
General 
(10) 
 
1. Similarities 
between the 
participant?s and 
client?s 
status/cultural 
experiences/cultural 
backgrounds 
enhanced the 
therapeutic 
relationship 
Typical (7) ?I was brought in [to work with a Chinese 
international student who is suicidal] because 
of my language skill, my native language is 
Chinese.  we speak Chinese through the 
whole session, and the client responds real . 
She feel comfortable talking with me, she 
feel more comfortable talking [in] Chinese, 
and then I guess that?s helpful, she feel that I 
could understand her and when she said 
something I could respond to her and show 
that I could understand because I am also an 
international student? .(QZ)  
 
?There was one client who was African 
American male, and then he was struggling, I 
was in kind of a smaller town, predominantly 
white, and he was having a hard time 
adjusting to be in this white dominant 
society, and he was originally from more 
south state, and he said he, he said he, he 
expressed he was relieved because I am 
Asian and I am obviously foreigner, and so 
he thought ?ok, she might know how I feel 
and she might be able to help me to really 
reduce like the stress and frustration about 
being in this society and being different in 
color skin?. Then I think my background like 
actually helped because as a Korean 
Japanese, I also experienced a kind of 
discrimination in my own country, so that 
helped me to connect with him or be more 
empathetic with his situation.? (RK) 
2. Participant?s 
understanding of 
Asian cultural 
norms helped 
therapy 
Variant (5) ?For the parts when [C] ask about my age 
and my marital status, I feel comfortable 
disclose to them. Because I just reframe it as 
a way that they try to know more about me ? 
and I think that is helpful to build working 
alliance. I don?t get a sense, I don?t feel like I 
need to analyze further ?why?. I just think 
that?s a general why they try to know more 
 
 122 
 
and be more connected with me, to find ways 
to connect with me. So I feel comfortable 
about sharing those information to them?..if 
a male Caucasian client who ask me how old 
I am and my marriage status, of course I 
would say, ?Hmm, interesting. Why you 
asking me this question,? and how that 
related to what we are talking about.? But the 
thing is, they are Asian and the elders, I feel 
comfortable to self disclose? (HC) 
 
?I remember I work with a Chinese-
 American in a hospital before. ..I feel like I, 
he want me to guess. Like he won't initiate 
conversation directly talking about his 
issues? If I was American, or was born in 
America, I would interpret this case as very 
resistant or is not opening up to, like, talk 
about his issue. But if we looked at this case 
from Chinese culture background, we would 
see, OK maybe C is nervous and he is relying 
on the expert to know what is going on with 
him.? (WX)  
3. Participant?s 
acculturation 
experience/bicultura
 l experience were 
helpful 
Variant (3) ?This client is bi-culture too, because she 
spent some time in the states when she was 
younger. so am I. I adopted some of the 
American culture. ? she has a desire to hold 
on to her home culture, but she has some 
beliefs that does not follow her home culture 
norms. And she was upset about that. So like 
the internal conflict that she experience, but 
when I say ?that?s ok, you know, you can 
embrace both [cultures]? that was such a 
permission for her, and she was like ?oh 
wow?. that really kind of reduces some of the 
burden that she felt, because I think at the 
level she felt she could only be one way. If 
she?s a little bit different from her home 
culture, that?s a betrayal. So she actually does 
not like part of herself who behave or 
thought differently from those people in her 
home culture. So for me to relate to that 
[struggle with navigating two cultures] and 
normalize that it?s okay to embrace both 
cultures, it encourage her to own that part of 
herself. It seems to be a very encouraging 
 
 123 
 
message for the client. Definitely seems like 
she was really struck by the feeling that she 
can do that, she can have both? (YH) 
B. Self-disclosure of 
participant?s cultural 
background/experien
 ce in the positive case 
Typical (6)  
1. Participants self-
 disclosed in order to 
build connection 
with the client 
Typical (6) ?When C mention about his immigrant 
background and how hard it is for him to get 
promoted and stuff like that, Somehow I can 
relate to it. Yeah, I did mention about my 
own my own cultural background and 
experience of coming from a different 
country. Blah, blah, blah. So yeah. But not 
like in details. Not whole story. I mention a 
little bit. It helped him to feel that I 
understand him? (WX) 
 
?well I also lived in the Midwest, when I was 
a kid I lived in, Illinois, and, there were a lot 
of international students there, but it was still 
the Midwest, and there were a lot of white 
kids there, and sometimes it did feel like I 
was discriminated there too. Even though I 
was pretty young. So, I shared that with her 
[the client]. I wanted her to know that I could 
understand, maybe not all, but some of the 
experience that she went through when she 
was a kid? (MS) 
2. Participants self-
 disclosed in 
response to the 
client?s inquires 
Variant (3)  ?I think the main thing I disclosed was the 
attitude towards nature and environment in 
Japan? the client knew I am Japanese. later 
on the client brought up the culture 
difference about nature and ask me about 
how nature is viewed in Japanese culture? 
(YK) 
 
3. Participants self-
 disclosed in order to 
normalize the 
client?s experience 
Variant (2) ?And so I feel like I share, actually I share 
my culture background, my experiences, and 
I think she was, sounds pretty uh, 
comforting, for her to know that she wasn?t 
alone in experiencing, you know what 
happened in her daily life? (YH) 
C. Discussion of cultural 
similarities or 
differences 
Variant (5) ?I would say I ask a lot of questions.  I also 
would ask straightforward questions, I would 
say ?what does that say about your culture? 
 
 124 
 
You?re telling me all this? and then she 
would very directly articulate what that 
means to her. And I would talk about my 
culture too.  I say ? Yeah, you know, I come 
from this culture? and I say to her ?sometimes 
in my culture we do these things too, do you 
feel that they are similar?? she would say 
?yeah? so actually towards she knows where I 
come form and she actually asks about it. 
Later when she say that ?you probably know 
this, being a Chinese and blah blah blah? like 
that and I would say ?yeah? or I would 
disagree so we do engage in a lot of 
discussions that would relate to our 
backgrounds.? (YH) 
 
D. Comfort in discussing 
culture 
Variant (4) ?I felt that I felt very comfortable [discussing 
cultural issues with C] because I think that it, 
that those kinds of conversations she, like she 
needed those kinds of conversations and I 
think, yeah having those kinds of 
conversations would be helpful for her, so, so 
I felt very comfortable? (JJ) 
 
?And also, when I gain more insight into my 
own cultural heritage, I feel more 
comfortable about initiating discussion of 
culture?. (WX) 
 
?I:L how did you feel about talking about 
your culture with her? 
P: comfortable, um, excited I think because I 
have done the exploration myself and I think 
that I am continue doing that, it?s not like it?s 
done. So when my clients, in particular this 
client, became curious about my background 
and I have that excitement of sharing it, but a 
part of me want to be cautious of not turn the 
session become me. Sort of not turning the 
space for me to talk about my experiences, 
and try to be careful, I try to think from the 
perspective of ?why the client ask me this 
and what can I share to be helpful to her? so 
there a piece, part of me feel a little bit 
cautious about questions like that because 
you can get so ?let me tell you!? (YH) 
 
 125 
 
E. Cultural discussions 
were helpful 
Variant (3) ?I think I sharing my experience of studying 
abroad and talking about my culture 
background, and also, talking about C?s 
culture background and like, any differences 
C might face in the future. Those kinds of 
conversations I think let her, let C have more 
confidence about studying abroad because 
she like  already have those kinds of 
conversations so she can make her prepared 
better. So, yeah so I think it?s helpful for her? 
(JJ). 
 
The Impact of the 
participant?s cultural 
backgrounds on therapy in 
the challenging case 
  
A. Negative effects of 
culture 
General 
(10) 
 
1. Participant?s 
cultural 
values/experience 
negatively 
influenced his/her 
intervention/concep
 tualization of the 
identified client 
General (9) ?Client?s name actually resembles one of the 
very well-known musicians in 60s, but I 
didn?t know that.  When I told my supervisor 
and other peers in practicum class (what the 
client?s name was), they were like ?oh, that?s 
his name?? I was like ?oh, why you all look 
so surprised?? People felt like the client used 
the same name (as the famous rock star) 
spoke something about this person?s 
personality. But I didn?t know cause I didn?t 
have the context. So yeah, I think that um, 
kind of restricted? (YH) 
 
?Yeah, yeah, okay. So, in my culture, 
interdependence is valued. So, I wasn?t 
taught to be independent. I went to a different 
town to attend college, but I still feel my 
parents? place is my home. So, so I don?t 
have the idea that I need to move out from 
my family or  I should be an independent 
person when I turn eighteen. I didn?t have 
that kind of idea, and I think even after I go 
to work I graduate from college, I would 
continue to live with my family, and I think 
everyone do that in my culture. But that?s 
really different from the U.S. culture. Many 
of my (American) clients think when they 
turn eighteen, they move out, their family. 
 
 126 
 
And they should be financial independent. 
And they should support themselves, and, 
but, yeah that?s very different from my 
values. I found it hard to relate to them.? 
(PT) 
 
?I?m thinking if C is not Asian American. If 
he is African American, if he is Caucasian 
American, if he is Native American, I 
probably would have more freedom, feel 
more comfortable to do other interventions, 
to deepen the affect or have less counter-
 transference. Maybe it?s because the similar 
experience that we have culturally. Well, I 
feel like I didn?t even ask him enough about 
his culture, his values, his background. But 
just simply being biased by the similar 
outlook, the similar color skin, then I assume 
that, I automatically assumed that he is like 
other Asian Americans. I guess that is the 
biggest mistake I made at the time? (HC)  
 
?I should?ve made a process comment but I 
didn?t. I think a process comment is not 
technique used in daily social conversation in 
any culture, clearly But in my culture I think 
it?s really taboo thing to do. So, I feel like 
that kind of process comment is very pure 
umm, counseling technique. So I don?t feel 
comfortable using it with this client? (YK) 
 
2. Participant 
perceived the 
identified client 
distrusting him/her 
or feeling 
uncomfortable 
working with the 
participant because 
of  participant?s 
international status 
Variant (3) ?A male Caucasian client, he questioned 
whether I could help him because I came 
from a different cultural background. I was 
feeling kind of uncomfortable working with 
him because of that?. (MS) 
B. Attempts to address 
the negative impact of 
participant?s culture 
Typical (6)  
1. Participant 
disclosed his/her 
Variant (5) ?so in the first session, I told her I am an 
international student and non-native speaker 
 
 127 
 
cultural background 
to the client and 
process the client?s 
reactions  
of English and asked  how is it for her to 
understand me and how does she feel about 
communicating with me. And, yea?. She 
said  It?s more challenging but she could 
understand me?  (YK) 
2. Participant 
emphasized on 
universality of 
human experience 
and reassured the 
client of the 
participant?s ability 
to understand the 
client 
Variant (2) ?I: when C questioned your ability to 
understand him because of culture difference, 
how did it go? 
P: Well I explained to him that there are 
some common experience across cultures and 
I could relate to him on these aspects. And he 
was, he was curious. He, he looked more 
curious about how I could understand him in 
a way than being like ? I can?t trust you 
because of difference in our the cultural 
background?.. And, after I explained to him, 
he seemed to understand and accept it.? (MS) 
 
C. Lack of cultural 
discussion in the 
challenging case 
Typical (6) ?I:  how much did you talk about culture 
issues in this case? 
P:  um not at all I?d say. The first reason is 
we didn?t have much time. We know that we 
have limited amount of session because I am 
leaving the site. Second of all, her concern 
doesn?t really benefit hearing my culture 
background that much? (RK) 
 
East-Asian trainees? 
training experience in the 
US 
  
A. Helpful components of 
clinical training in the 
US 
  
1. Training in 
counseling theories 
and/or skills 
Variant (5) ?I think I feel confident with psychotherapy 
theories, I feel more theoretically confident. 
Yeah I read a lot. I?ve been reading a lot 
about theoretical approach and so I receive a 
lot of training about different approach, 
especially in the XX area there are tons of 
professional schools and organizations I can 
learn from? (case WX). 
2. The opportunity to 
provide 
therapy/counseling 
to real clients 
Variant (4) ?I think just having this real counseling 
experience with real clients is the most 
important aspect of training a therapist. You 
can read counseling books or articles, but it?s 
not really?a completely different thing to 
 
 128 
 
kind of, practice it with real people. So I feel 
really kind of confident and solid about my 
clinical skills because of I have gone through 
from one setting to another and different 
levels of practicum training...[Practice is] the 
only way you learn how to, sort of like 
implement different counseling skills, 
whether it?s micro skills like listening, 
reflecting, providing empathy or something 
advance like the empty chair or guided 
imagery. ?You are trigger by any clients 
that you will get to work with. You are 
triggered by different things in different ways 
or about different things. I think those really 
provide very rich opportunities for you to 
examine your blind spots. You get to see 
your strengths, but most importantly you get 
to see your weaknesses and areas that you 
should improve on in order to become a more 
effective therapist? (case YH) 
3. Supervision Variant (4) ?I have really benefited from very very good 
supervisors, and I just cannot imagine 
without them, how different my experience 
would have been. They have really impacted 
my confidence about just being a therapist in 
general (and) my confidence about speaking 
English, doing therapy in English. And it has 
really helped me to understand the dynamic 
between me and someone who is different 
from me, in a clinical setting? (case YH) 
4. Multicultural 
training/opportuni
 ties to work with 
diverse clients 
Variant (3) ?I think the multicultural training I received 
in the US will be the most helpful to my 
practice back to my home country?.being 
trained in such a culturally diverse society 
helped me sharpen my awareness sensitivity 
for different aspects of cultural diversity. 
And seeing the cultural context of 
international student makes me be critical of 
my hypothesis, my assumptions about a lot 
of things. ?.I think I can be a more 
culturally sensitive therapist when I go back 
to my home country. 
 
I remember before I came to the US, I 
thought everybody is the same... But then 
when I come to the US, I recognize, Wow, 
 
 129 
 
there is so much more to learn about 
multiculture.  And then I recognize that there 
are diversity in my home country. ?.So now 
I am more and more interested in the cultural 
diversity in my home country and  will do 
some more research about that? (case HC) 
 
5. Support/encourage
 ment from 
practicum 
sites/academic 
program 
Variant (2) ?People in my program yeah they are very 
patient and very understanding about having 
international trainees there. so, yeah,  they 
are very open to having any kind of 
discussion and  often times invited me to 
have discussion about any difficulty referring 
to culture difference or culture gap or 
whatever, including my acculturation levels, 
so I really appreciate that? (case RK) 
B. Areas in need of 
improvement in 
clinical training 
  
1. A lack of cultural 
sensitivity in 
supervision and/or 
academic 
programs 
General (8) ?last year actually I am doing a practicum in 
another agency and early on the supervisor  
didn?t give me any clients..  later on she told 
me what happened.. She told me at first she 
at first she was really concerned you know 
about my language skills, my client will be 
very tough on me she?s trying to protect me 
so you know that kind of stuff, so at first I 
don?t have any clients, for the first few weeks 
because she?s concerned about it? (case LT) 
 
?I usually bring up discussion of my cultural 
identity in supervision and I don?t think a lot 
of the times it draw attention of the 
supervisor? (case QZ) 
 
?I would appreciate the professors or the 
program can really take international training 
seriously and at least they have some 
experience working abroad or teaching 
abroad. So they would be more aware of 
international students? needs, instead of 
letting students struggle and advocate for 
themselves. Especially if they just came to 
the states and they don?t know anything 
about this mental health field. Actually I am 
the only one in the program that is 
 
 130 
 
international.? (case WX) 
2. Not enough 
multicultural 
training in 
academic 
programs 
Typical (6) ?if I could see more clients from the same 
country as me, .. or study a certain specific 
topic related to a specific cultural group in 
my home country, of course that would 
definitely be more helpful. Or have a seminar 
specific, study topic related to my culture of 
origin; that would definitely be more helpful 
for me.? (case HC) 
3. Need more 
opportunities to 
work with diverse 
client 
Variant (3) ?Maybe, it?ll be, like, it?ll be better for me to 
have more chance to see like diverse clients, 
including people from, like, same country as 
me. Yeah? (case JJ) 
 
Note. N = 10. ?General? indicates that this category occurred for 9 or 10 participants; 
?Typical? indicates that this category occurred for 6 ? 8 participants; ?Variant? indicates 
that this category occurred for 2 ? 5 participants. 
 
 
 131 
 
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